Expecting the Unexpected: When Use of Complementary Alternative Medicine Goes Wrong

Complementary and alternative medicine (CAM) is a broad set of health care practices that are not integrated into the dominant health care system (1). In recent years, use of CAM has surged, with 33% of the U.S. population having tried CAM and up to 60% of patients reporting use of CAM in the past year (1,2). CAM treatments are most commonly used in chronic conditions without well-established treatments. The most commonly reported CAM modalities include herbal supplements, dietary modifications, mind-body practices and neuro-feedback (3,4). Common herbal CAMs include St. John's wort, kava, and omega-3 fatty acids. Psychiatric conditions commonly treated with CAM include anxiety and depression. Acupuncture, aromatherapy, and mindfulness-based meditation practices are commonly recommended CAMs for reducing anxiety among the general population.

Despite their widespread use, the majority of CAM modalities are not evidence based, and many have the potential for adverse effects. The risk of adverse outcomes is further amplified by lack of physician-patient communication regarding the patient's use of CAM (3,5). Examples of adverse outcomes include exposure to heavy-metal toxins and liver toxicity. Many patients obtain this information from the Internet without confirming the reliability and safety of the medical advice with a physician. Many patients are unable to adequately assess this information, which can lead to adverse outcomes. This report details the case of a patient with attention-deficit hyperactivity disorder (ADHD) and anxiety who was hospitalized in an inpatient psychiatric unit after using turpentine as a CAM.

Case

"Mr. B" is a 21-year-old Caucasian male who was brought to the emergency department by his college roommates for "abnormal behavior over the past month." They suspected that the patient had made a suicide attempt by toxic ingestion and requested an evaluation. His friends noted he had become progressively withdrawn over the past month, expressing unusual thoughts, including "government's plan to demasculinize men by poisoning tap water." Previously, the patient was a socially active college junior with close relationships. His friends became concerned after he reported drinking turpentine to "cleanse his body."

In the emergency department, his vital signs were within normal limits. His physical exam, laboratory studies, and urine drug screen were unremarkable. Regarding his past psychiatric history, he had been diagnosed as having a specific learning disorder, with impairment in reading, and attention-deficit hyperactivity disorder (ADHD). Later, at age 18, he was given a diagnosis of generalized anxiety disorder (GAD) by his primary care provider. He had no prior psychiatric hospitalizations. He denied suicidal ideation, symptoms of depression, and auditory or visual hallucinations. However, he admitted to using turpentine earlier in the day. He was referred by the emergency psychiatrist to the inpatient psychiatric facility for possible psychosis and posing a danger to self.

Mr. B was evaluated at the inpatient facility the following day. Upon interview, he was noted to be moderately anxious but cooperative, without perceptual disturbance. His thought process was organized. He displayed no signs of mania and denied auditory or visual hallucinations. He denied any suicidal ideation. Interview of the patient revealed he was in special education from first through 12th grade. This led to his self-reported feelings of isolation, low self-esteem, and subsequent anxiety. He reported being treated with stimulant medication for ADHD from ninth through 12th grade, but he denied symptomatic improvement. He continued to have poor concentration and poor school performance as a result. He discontinued his medication after starting college while searching online for more "natural treatments." He came across several websites that considered the conventional health care system as the cause of ADHD and learning disabilities. He made extensive dietary changes and stopped using all conventional medications. In addition, he started a "natural detoxification regimen" with turpentine and cane sugar to "cleanse his body of toxins that have accumulated over the years from ADHD medication." He reported experiencing chronic fatigue and "brain fog" for many years, which was immediately improved after his first use of turpentine.

Initially, the team had no knowledge of turpentine being promoted as a CAM. However, further investigation confirmed the patient's claims that "turpentine is sold as a natural supplement to promote health, slow aging, and cure a wide range of diseases." Medicinal turpentine was highly reviewed online and sold on multiple well-known websites, including Amazon. He was educated on the use of alternative medicine and the inaccuracy of online information. The inpatient team did not believe the patient was using this product with the intent to cause direct harm to himself.

Mr. B maintained his ideas about natural products and refused any medication while hospitalized. He was provided an outpatient follow-up appointment for 2 weeks after discharge. He was receptive to education about making informed decisions and the risk of using potentially toxic products as alternative medicine. The patient did not attend his outpatient appointment and was subsequently lost to follow-up.

Discussion

Use of CAM therapies is common among psychiatric patients. The highest reported rates of use are for autism spectrum disorder (ASD), ADHD, GAD, and major depression (1–3). Some psychiatric patients report using CAM therapies as part of a cultural tradition. Traditional Chinese medicine has been practiced for thousands of years. Common treatments include acupuncture, cupping, herbal remedies, and tai chi, all of which have been reported to reduce anxiety and stress. Others report using CAM therapies as adjuncts to pharmacological medications or in place of traditional treatments. However, the most commonly cited reason for use has been patient concerns with the safety of conventional psychiatric medications (6).

Despite their widespread use, only a few of the psychiatric CAM modalities have been subjected to randomized controlled trials. Among those, only light therapy, mind-body practices, cognitive training, S-adenosyl methionine, zinc, magnesium, and omega-3 supplements have demonstrated therapeutic benefit (1, 2).

The majority of psychiatric patients do not disclose their use of CAM to their physicians. Only one-third of psychiatric patients report their use of CAM to their physicians (6). Patients consistently cite physicians' perceived lack interest or limited knowledge about CAM as the reason for the lack of disclosure (6). This forces many patients to use Internet searches and anecdotal evidence in place of sound medical advice. Up to 9% of patients with ASD have been exposed to the potentially harmful effects of CAM (3). One CAM therapy being touted as a natural and effective cure for pathogens and neuropsychiatric conditions is turpentine.

Turpentine is an aromatic hydrocarbon mainly composed of monoterpenes α- and β-pinenes. Uses include organic synthesis and as a solvent for oil-based paints (7, 8). Turpentine has a long history of medicinal use. Hippocrates used it for the treatment of lung disease and biliary lithiasis, and in ancient France it was recommended for blennorrhoea and cystitis (9). Turpentine was also widely used as a wound disinfectant due to its antimicrobial properties (10). In ancient Rome, turpentine was used as a fragrance and to enhance the scent of urine (11).

However, the therapeutic use of turpentine largely subsided after the discovery of its severe toxicity. Turpentine, similar to other aromatic hydrocarbons, leads to dose-dependent toxicity on multiple organs. At low doses, turpentine can result in irritation of the airways, lungs, mouth, and esophagus, along with nausea, vomiting, pupillary contraction, dizziness, drowsiness, and hematuria. At higher doses, turpentine may cause severe and possible fatal problems, such as aspiration pneumonitis, severe pulmonary edema, cardiac arrhythmias, hemorrhagic gastroenteritis, liver and kidney failure, toxic glomerulonephritis, and resistant metabolic acidosis (12).

Turpentine also disrupts the delicate biochemical balance of the central nervous system, leading to a dose-dependent neuropsychiatric disturbance. In the short term, low-dose turpentine has analgesic, anxiolytic, and sedative effects (9). Some studies report it may cause psychostimulant effects, resulting in euphoria and improved concentration (9). Reports of turpentine being used to treat depression and insomnia have surfaced (13). On such study described the psychotropic effects of turpentine as "a pleasant feeling of warmth in the stomach, later followed by a mood of exhilaration and mental changes before going on to damage the lungs, kidneys and liver" (13).

Although the exact mechanism of action remains poorly understood, turpentine is thought to increase GABA and glycine synaptic stimulation of pyramidal neuron, thus inhibiting the pyramidal neuronal functions and resulting in a disruption of normal cognitive processes. It may also activate dopaminergic neurons in the mesolimbic pathway, causing increased dopamine concentration in the caudate nucleus and nucleus accumbens. This may explain the euphoria and improved concentration experienced by some patients. Chronic turpentine exposure, however, leads to toxic encephalopathy associated with chronic fatigue; depressed mood, and impairments in memory, concentration, abstract thinking, and judgment. These impairments may lead to long-term personality changes and inability to sustain normal function (14).

Most patients do not disclose their use because physicians forget to ask, and patients do not see these practices as dangerous. Psychiatrists can ask, "Are you using any over-the-counter supplements or alternative treatments outside of your prescribed medication?" Physicians can further elaborate by giving specific examples, such as, "Do you take any supplements that enhance mood, improve athletic performance, or improve overall health?" Many physicians will need to educate themselves on the efficacy and safety of CAMs to help patients make informed decisions.

Key Points/Clinical Pearls