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

We describe a 30-year-old man who was admitted to our hospital complaining of “being drugged with methamphetamine,” along with psychotic and homicidal features, likely caused by four-month use of an over-the-counter (OTC) performance-enhancing supplement (PES) product containing dendrobium extract and L-dopa (L-3,4-dihydroxyphenylalanine). The patient denied a history of psychotic illness. He had abstained from anabolic steroids for four months and from alcohol for two months before admission. Treatment with oral olanzapine during the patient’s 13-day hospitalization led to the resolution of his psychosis and homicidality. He was discharged to outpatient care with a primary diagnosis of substance (PES)-induced psychotic disorder (resolved). Because of our inability to ascertain the precise chemical structure of the PES product the patient had used, we based his diagnosis on: 1) the clinical presentation (psychosis, homicidality, and “feeling drugged with methamphetamine”); 2) the longitudinal and recent history (psychiatric and substance-use history, and use of hormones and OTC PES products) obtained from the patient and his family; and 3) the use of a PES containing L-dopa and dendrobium extract, and literature reporting the adulteration of PES products with synthetic methamphetamine analogues. Current knowledge of the safety profile of PES products and of the risks associated with their use is limited by the lack of Food and Drug Administration (FDA) pre-marketing regulations, by the minimal research into PES products, and by patients’ underreporting of their PES use.1,2 With this case report, we wish to bring the risk of potentially severe psychiatric problems caused by the use of OTC PES products to the attention of practitioners.