The Automatism Dilemma-distinguishing Overdose from Intent: A Case Report with Review of Literature

Abstract

Drug automatism is an uncommon and debated phenomenon, first described by Richards in 1934, in which an individual repeatedly consumes a drug without awareness of their actions or subsequent recollection. It is most frequently reported with barbiturates such as phenobarbital. The proposed mechanism suggests that an initial therapeutic dose alters consciousness and judgment, leading to repetitive intake until toxic or fatal levels are reached (i.e consumption of all the remaining tablets until the source is empty). Distinguishing automatism from intentional suicidal poisoning carries significant clinical and medico legal implications. We report a case of 16-year-old male with epilepsy, treated with phenobarbital 30 mg daily for three years. Following seizure relapse nine months before the event his dosage was increased to 60 mg. In the three months before the event, he was permitted to self-administer his medication. One morning at 4:00 AM, he was discovered unresponsive with shallow breathing, cold extremities, and an empty bottle of phenobarbital 60 mg beside him. History revealed ingestion of 54 tablets totalling 3.24 g within six hours, a potentially fatal dose (2–10 g). He received supportive care and two sessions of hemodialysis, after which he recovered completely. Psychiatric evaluation excluded depression or suicidal intent, and he had complete retrograde amnesia of the episode. This constellation strongly supports drug automatism, emphasising the diagnostic challenges and forensic importance of differentiating it from deliberate overdose.