Tobacco dependence with psychological and behavioural disturbances in a young adult treated with homoeopathy – a case report

INTRODUCTION

Tobacco use disorder is among the most prevalent, deadly, and costly of substance use disorders. It is also one of the most ignored, particularly by psychiatrists. Despite recent research that shows commonalities between tobacco use disorder and other substance use disorders, tobacco use disorder differs from other substance use disorders in unique ways.¹

Tobacco use disorder remains responsible for the majority of preventable deaths in the Western world.² Worldwide, nearly 1.4 billion people regularly use tobacco. In 2019, the World Health Organization (WHO) announced its first-ever projected reduction in the number of men who use tobacco, with a total anticipated decrease of nearly 60 million individuals who use tobacco.^3,4 According to WHO, it is expected an increase of 10 million deaths a year in the world from tobacco smoking by 2030. It has not only caused the death of active smokers but about 6,00,000 deaths from second-hand smoke. Tobacco dependence is usually associated with psychological and behavioural disturbances. It is also related to many non-communicable chronic diseases like diabetes, hypertension, obesity and ischemic heart diseases and predisposes to many communicable diseases like recurrent respiratory infections.⁵ The most significant challenge facing smokers who wish to quit are nicotine withdrawal symptoms; these include dysphoric or depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate and increased appetite or weight gain (American Psychiatric Association, 1995).⁶

Nicotine is the main active ingredient in tobacco products that reinforces individual tobacco addiction behaviour, and it is tobacco's other components which cause widespread mortality and morbidity.^7-9 The Food and Drug Administration has approved many first-line drugs for tobacco use cessation. Bupropion and varenicline are the nicotine replacement therapies, among which the latter was found to be more successful in helping patients quit tobacco use, but both drugs have various side effects, including psych morbidity.¹⁰ Therefore, an effective pharmacological aid with minimal side effects was needed. However, homoeopathy medicines such as Staphysagria, Nux vomica, Tabacum, Avena sativa, and Caladium have properties which render them helpful in reducing tobacco cravings.¹¹ According to a United States patent application, "Homeopathic method and system for treating nicotine addiction," similar homoeopathic medicines were used, which helped in reducing the nicotine craving and detoxification of residual nicotine and nicotine byproducts.¹² The Fagerström Test for Nicotine Dependence is a standard tool used to measure how physically dependent a person is on nicotine from cigarette smoking, providing a score that reflects the intensity of their addiction.¹³ There is significantly less literature on the efficacy of homoeopathic medicines for reducing tobacco use is available in the online database. Hence, this case report highlights the positive role of homoeopathy treatment for tobacco use disorder effectively.

CASE REPORT

A 24-year-old male consulted with an uncontrolled habit of cigarette smoking for 11 years, associated with violent anger aggravated for two weeks at Psychiatry OPD of NHRIMH, Kottayam. He had presented with severe restlessness, getting out of the home frequently, irritability and frustration for not being able to stop smoking, anger outbursts, <contradiction. Demanding money often for cigarettes and smoking, abusive talks, suicidal threats, hurting tendency towards family members, destructiveness, diminished appetite and thirst, severe weakness, headache and reduced sleep.

History of presenting complaints

Complaints of cigarette beedi smoking started at the age of 13 while he was studying in eighth standard. He started it as a part of the company with friends. Initially, it began as a social smoker, and it is one 2-3 cigarettes/day. Subsequently, increased cigarette smoking. He was average in his studies from the beginning, but due to increased usage of increased usage of tobacco, he became utterly backward in his studies. He passed the tenth exam with minimum marks and discontinued his studies afterwards. He started going to work as a mechanic, but he was irregular. He used his earnings to buy tobacco products. Afterwards, he stopped working and demanded money from his parents. If they are not given, he will become violent, hurt everyone and destroy entire household things. Later, he went for a job to make money for buying cigarettes and beedi. At the time of admission, he was using 45 cigarettes/day and occasional alcohol use (His last usage 30 days back was 150 ml of beer). His complaints increased day by day, so his parents brought him to NHRIMH, Kottayam, and he was admitted to IPD and started taking homoeopathic medication.

Treatment history

History of use of antipsychotic medicines on psychiatrist advice.

Past history

The patient had no relevant medical or psychiatric illness history.

Family history

The patient's father is a chain smoker, uses Hans and is a chronic alcoholic, too.

Life space investigation

The patient was born on a full-term normal vaginal delivery, and there were no prenatal, natal or post-natal complications. He was born and grew up in Kottayam as the second child in his family. His milestones were typical. He started schooling at 4 years of age and was average in his studies. He maintained a strong bond with his family, particularly with his mother, to whom he was very attached. However, he had a strained relationship with his sister, feeling envious of the attention and priority she received from their parents. This led to frequent arguments between them. From a young age, he was eager to socialise and formed a large circle of friends. His relationships with his peers were generally positive until he started using substances.

Mental generals

From childhood, he exhibited an obstinate nature, was highly dependent, and often displayed cowardice, sensitive to criticisms.

Physical generals

His appetite was less, thirstless, and his bowel movements were regular. His sleep was inadequate. He had an intense craving for fish and fried foods but also an aversion to vegetables. He generally preferred warmth and avoided covering himself, showing a preference for being fanned. And there is increased salivation. He was ambithermal.

Clinical findings

The patient was thin and underweight (42 kg, height-152 cm). No other abnormality was detected during the general physical examination.

The mental status examination findings showed that the patient was cooperative, conscious, and reserved. Eye-to-eye contact was maintained, and interpersonal relationships were poor. Psychomotor activity was increased. The speech was relevant, the rate, volume, and tone were increased, and reaction time was normal. Affect was appropriate, reactive, stable and congruent. His mood was subjectively sad, and objectively, he was dull, and at the same time, he was irritable, too. The flow of thought was increased, and the patient had an inferiority complex. He had no perceptual disturbance and was oriented toward time, place, and person. Immediate, recent, and remote memory was good. He was good at general information and intelligence. Concentration could not be maintained. Abstract thinking was sound, and social judgment and test judgment were adequate. The patient had insight regarding illness.

Diagnostic assessment

Mental and behavioural disorders due to tobacco dependence F-17.24 (ICD-10). The consultant psychiatrist has diagnosed the condition based on the high dependence on tobacco for 13 years and associated with behavioural issues like increased irritability, violent anger, suicidal tendencies, and abuse talks.

The severity of tobacco dependence was assessed with the FTND scale at baseline, and the total score was found to be 8 (severe dependence).

Therapeutic intervention

Initially, Nux Vom 30 TID was given to manage withdrawal symptoms. Once the patient was relieved from the withdrawal symptoms, all the symptoms obtained from detailed case-taking were analysed, and characteristic symptoms were converted to rubrics. Radar Opus 2.2.16 software was used for repertorization, as in Figure 1.¹⁴ The single homoeopathy medicine Staphysagria was given based on the totality of symptoms and repertorization in consultation with Materia Medica.¹⁵ Staphysagria was given in repeated doses. Lorazepam 2 mg (0-0-1) and antipsychotic medicine olanzapine 10 mg (0-0-1) were given along with homoeopathic medicines as per the advice of the consultant psychiatrist. Lorazepam was given only for 3 days and stopped afterwards, and olanzapine continued for one week. After that, the dosage was reduced to 5 mg for 1 week and sopped afterwards. The patient has been under homoeopathy medicine till the last visit.

Follow–up and outcomes

After taking medicine, withdrawal symptoms subsided. The craving for tobacco gradually reduced within 1 month. A significant improvement has taken place with Staphysagria in LM potency. Patient follow-up was assessed every day or as required. The detailed follow-ups are summarised in Table 1. Craving for tobacco and smoking cigarettes was not observed in the follow-up period till the last visit. The patient became normal in behaviour and stopped smoking entirely within 3 months of homoeopathic treatment. Change in the FTND score assessed every 3 months. The changes in tobacco dependence were assessed with the FTND scale score, which revealed a remarkable decrease in scores from 8 (before treatment) to 0 (after treatment) (Table 2). The Monarch inventory for homoeopathy score was +8, close to the maximum score (+13) (Table 3), revealing the positive relationship between Staphysagria intervention and free from tobacco dependence.¹⁶ No adverse effects were reported during the treatment.

DISCUSSION

Tobacco use is a pervasive public health problem and the leading cause of preventable morbidity and mortality. Consumption of tobacco has been a worldwide problem over the past few decades due to the highly prevalent tobacco-attributable complications.¹⁷ The treatment of adolescent cigarette smoking and tobacco use disorders, in particular, continues to be a substantial public health priority.¹⁸ Psychological and behavioural disturbances like anxiety, depression, violent anger, restlessness, abusive talks, and suicidal threats are usually seen in tobacco-dependent individuals. The current case also presented many psychological and behavioural disturbances and was very obstinate to take treatment and be in the inpatient department. Nux Vom 30 TID was given to manage withdrawal symptoms. During the first three days, we faced many challenges in keeping the patient admitted to IPD, such as refusing to stay at IPD, violent anger, sleeplessness, striking others, and threatening suicidal attempts. Withdrawal complaints were managed with Nux vom 30, lorazapam for sleeplessness, and antipsychotic medicine olanzapine for addressing psychological disturbances. Gradually, within a week, the patient responded well and started cooperating with treatment. In continuation, based on his mental, physical and other symptoms, Staphysagria started in daily repeated doses. A case report suggests that homoeopathic medicines in 50 millesimal potencies have demonstrated significant effectiveness in treating chronic diseases.¹⁹ In response, all his behavioural and psychological disturbances became under control, and his tobacco craving was also reduced. After 1 week, antipsychotic medicines were stopped, and the patient was kept only under homoeopathic treatment for 1 month at IPD.

Later, based on the marked improvement, he was discharged with the advice of continuing homoeopathy medicines. A considerable period of tobacco abstinence is necessary to overcome dependence on it, the same was ensured in the IPD treatment. The patient regularly visits OPD NHRIMH, Kottayam, and there is no use of tobacco or craving for it till the last visit. FTND scale is used to assess the intensity of dependence. The test was designed to provide an ordinal measure of nicotine dependence related to cigarette smoking. There was a remarkable decrease in scores from 8 (severe dependence, before treatment) to 0 (after nil dependence treatment).¹⁶ Staphysagria is one of the commonly indicated medicines for the harmful effects of tobacco and to reduce the craving for tobacco, as expected, it acted reasonably and caused a marked change in tobacco dependence. In a total of 6 months of homoeopathy treatment, the patient could reduce the craving for tobacco and its dependence. Hence, this case suggests the usefulness of homoeopathy in treating tobacco dependence. However, as this is a single case study and tobacco dependence is associated with a variable and unpredictable relapse of craving, well-designed randomised control studies with longer follow-ups may be taken up for scientific validation.

CONCLUSION

The transition from severe tobacco dependence to nil dependence suggests a positive role of homoeopathy in treating tobacco addiction. Since it is a single case report, a well-designed study with a large sample is recommended to prove the effectiveness of homoeopathy in treating tobacco dependence.

ACKNOWLEDGEMENTS

The authors would like to acknowledge the service and care of nursing staff toward the IPD patients at the National Homoeopathic Research Institute in Mental Health, Kottayam.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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