High and repeated use of MDPV induce chronic psychosis in patients with no psychiatric history

Background The 3,4-Methylenedioxypyrovalerone (MDPV) is a stimulant substance belonging to the cathinone and pyrrolidine classes. It is recognized as one of the most potent stimulants, primarily acting to increase dopamine, norepinephrine, and serotonin levels in synapses. Acute effects of MDPV include euphoria, rapid heartbeat, open-mindedness, increased energy, motivation, sociability, sexual desire and concentration, and decreased appetite. As the dose increases, the desired effects remain identical, but the adverse effects, such as anxiety and disorganized thoughts, escalate rapidly. At extremely high doses or with continued use, delusions and psychosis are frequent during the offset [3]. Multiple cases of MDPV-induced psychoses with severe behavioral agitation were mostly resolved through drug wash-out and psychopharmacological treatment. The case reported here is the most severe among 15 similar cases that we observed in our hospital in year 2023. Case report A 24-year-old man first came to our attention with positive psychotic symptoms (auditory hallucinations, persecutory delusional ideation, behavioral anomalies) following MDPV intoxication; after an inpatient psychiatric care the symptoms remitted with drug wash-out and acute antipsychotic therapy. Over the subsequent two years, he was enrolled in a high-support community. Despite experiencing extended periods of abstinence, he relapsed 13 times into MDPV use, exhibiting progressively worsening and prolonged psychotic symptoms, often requiring hospitalization (5 times). As the desired effects (euphoria, increased sexual desire, disinhibition) diminished and the dosage increased, the positive psychotic symptoms during the offset increased their severity and the negative psychotic symptoms became chronic and more distressful. These clinical findings were monitored with diagnostic scales: BPRS (50>63), PANSS (92>142), HAM-A (18>24). Neuroimaging findings ruled out brain abnormalities. To date, the patient has received a diagnosis of chronic psychosis maintained and exacerbated by the use of MDPV. No antipsychotic or craving medications have proven effective in reducing negative symptoms. DiscussionThe intake of progressively increasing doses of MDPV coincides with a high risk of chronicization of its psychotic effects and their persistence during periods of abstinence, in patient with no previous psychiatric history. The acute intake of MDPV increased the individual experience of gratification and compensation, while its repeated and/or high dose use contributed to the progressive worsening of the clinical picture during the offset. No psychopharmacotherapy has succeeded in reduce craving, negative symptoms, and anxiety. A careful long-term surveillance of MDPV intoxications, coupled with a thorough assessment of potential organ damage, is imperative due to the rising number of cases and the severity of symptoms.