Brain Trauma & New Onset Psychosis
Some years ago, I was asked to evaluate the reports of six experts who felt a young man's car accident had been of no consequence. I disagreed. They felt he was a certain Schizophrenic, and I felt they were twenty years behind on the effects of trauma as a cause of psychosis, and would say anything to be paid. Unfortunately, state boards and civil attorneys can find some "expert" to say anything for them, as long as they get paid.
Olfactory or "Smell" Hallucinations
There are many causes of smells that do not make sense. It appears that Mr. Jones, when he was younger, in 19xx, had some transient smell concerns. From the evaluations, it seems he was experiencing parosmia or a smell distortion, in which a scent was perceived as rotten eggs or feces. Or he experienced phantosmia, i.e., the scent was not there and he smelled something anyway. He also was unsettled by a body odor-like smell that was worse in the afternoon. He was unsettled by these smells and was anxious about them.
I do not think these were the early onset signs of schizophrenia for a number of reasons.
- Any anxiety or misattribution of a noxious smell or perception error will become increasingly solidified by worry about the smell experience.
- Both of these experiences mentioned above, smell distortion and phantosmia, are quite common.
- In contrast to childhood gradual-onset schizophrenia, this "hallucination" went away and he did not require follow up care. Schizophrenia hallucinations in youth do not float away and fully leave without treatment.
- Further, these smell experiences have many causes and even more are emerging. The other evaluators entirely ignored this large body of science. These causes of transient smell distortion include:
- Bacterial infection -- his ENT prescribed an antibiotic based on what he saw. Objectively this included "edematous nasal mucosa" on both sides, obliteration "of the olfactory cleft," "generalized erythema," ... and bulging of the fontanelles bilaterally." On his reading of the MRI he reports, "possible inflammatory disease within the crista galli and adjacent to the olfactory bulbs." So much for good nasal tissue.
- Viral or fungal infection -- Mayo researchers published in 1999 that 96% chronic nasal infections are fungal.
- Trauma -- this could be as simple as wrestling, play fighting with a brother to other common athletic bumps. Mr. Jones had significant tonsil inflammation, which required surgery and caused severe snoring and this might have been a consequence.
- Sleep disorder -- Mr. Jones had possible apnea before he had his tonsils removed surgically.
- Inflammation -- this complex system sends many chemicals to sensory nerves causing a wide range of distortions.
- Medications -- basic over-the-counter medications can cause smell distortion.
- Environment -- the youth reported this problem soon after working in a business as a pest control assistant apprentise. In this environment, toxicology research has shown that many irritating and confounding exposures exist; including dozen's of toxic volatile gases and aerosolized petroleum products. His office also had some past flooding and documented misc. molds with fair ventilation. Abnormal smells can occur in these settings. Smell is the perception of airborne molecules flying in and binding the receptors in your nose. Dozens of these chemicals are routinely in the environment he described. Both the ENT and Dr. Y mention this as a possibility.
- Common Essential Nutrient Abnormalities -- Most studies on child and adolescent nutrition show deficiencies of essential minerals. Some of these minerals are involved in basic functioning in hundreds of enzyme systems including optimal sensory nerve function.
- Medication Induced Depletions -- The patient was on minocycline during the period he complained of his problems with smell. This medication can cause depletions of nutrients required for normal nerve function. Smell is very dependent on optimal nerve function. Clinically, this often manifests as 1-2 small sensory abnormalities. Specific depletions may include: biotin, Vitamins B-1, B-2, B-3, B-6, B-12 and Vitamin K. Excess doses of some of these may also cause this problem.
- Emotional Exhaustion -- commonly can cause eccentric perceptions. Another common one is dysphoria of the skin after one has had an upsetting day.
- Migraines -- not all migraines are obvious and many just seem like tension. Olfactory or smell "auras" are common in migraines.
- Seizures -- a 24-hour EEG can be negative even with a positive seizure disorder. This patient's seizure work-up was non-existent. He had no 24-hr EEG or other tests.
- Hormone or Fluid Variation -- pregnant women routinely have variation in smell and have both hormone and fluid changes. An older adolescent boy in various hot work spots such as attics in Texas may also be having fluid shifts of hydration, at the same time experiencing increased testosterone, DHT and estradiol. DHT can cause acne at higher doses and from Dr. Y's materials we learn the patient had acne.
- General Allergies -- patient was being seen by allergist Dr. K.
- Specific Allergy to Minocycline
- Side Effect to Minocycline -- antibiotics can alter the sense of taste or smell.
- Congenital -- some are born with vulnerability to smell variation.
- Unknown Cause -- Surprisingly, research shows that a full 33% of medical complaints never find a cause.
In summary, it seems highly unreasonable to take a single smell experience that has many objective and reasonable causes, and say this was a rare early sign of impending schizophrenia. The youth had no other signs of any kind consistent with other hallucinations, delusions or social functioning change hallucination presenting. He certainly did not have the common early schizophrenia signs of auditory hallucinations, paranoid thinking, disorganized thoughts or relational impairment. He only reported years before his accident that he smelled some annoying odors. It is not common for Schizophrenia to be present with only highly rare olfactory symptoms.
So we are also asked to believe that this symptom appeared in isolation from other clear schizophrenia symptoms.
Finally, we are asked to believe this early "schizophrenia presentation" then disappeared for years without strong anti-psychotic medication. All these positions seem outside the realm of medical reasonableness.
Therefore, I believe the most reasonable position is to say that Mr. Jones' new onset sensory trouble was due to his severe head trauma.