Mental disorder due to

stimulant
Betty Rachma

stimulant
substances that induce a number of
characteristic symptoms, (alertness with
increased vigilance, a sense of well-being,
and euphoria)
classified by the US Drug Enforcement
Agency (DEA)

DEA classification
Schedule I
Schedule II

no accepted medical use

Have a high abuse potential.
cannot be prescribed.
a high abuse potential with severe psychic or physical
dependence liability.
Prescriptions must be written in ink or typewritten and must
be signed by the practitioner except in a genuine
emergency,

Schedule III

an abuse potential less than those in schedules I and I

Prescriptions may be oral or written, and up to 5 renewals are
permitted within 6 months.

Schedule IV

an abuse potential less than those in schedule III.

Prescriptions may be oral or written, and up to 5 renewals are
permitted within 6 months.

Schedule V

an abuse potential less than those in schedule IV

generally for antitussive and antidiarrheal purposes

DEA classification
Schedule I

Schedule II

Schedule III

Schedule IV

Aminoxaphen Cathinone
Fenethylline
Methcathinone
Mephedrone
Methylaminore
x
Amphetamine
variants

Cocaine
Dextroampheta
mine
Lisdexamfetam
ine dimesylate
Methampheta
mine Methylphenidat
e Phenmetrazine
Biphetamine

Benzphetamin
e Chlorphentermi
ne
Clortermine
Phendimetrazi
ne tartrate

Armodafinil
Diethylpropion
hydrochloride
Fencamfamin
Fenproporex
Mazindol
Mefenorex
Modafinil
Norpseudoeph
edrine
Pemoline
Phentermine
Pipradrol
Sibutramine

Schedule V
pyrovalerone

Clinical Presentation
Physical

Increases in blood pressure, heart rate, and pupillary dilation

are common. Stimulant use may result in hyperthermia,
hyponatremia, arrhythmias, myocardial infarction, and
hemorrhagic stroke.

Mental status
examination
(during
stimulant
intoxication)

Attitude - Tense, anxious, restless, agitated

Psychomotor activity - Increased; dyskinesias may be
present
Mood/affect - Good/euphoric or irritable and labile
Speech - Talkative
Thought processes - Flight of ideas; tangentiality
Thought content - Paranoia; auditory, visual, and tactile
(formication) hallucinations; grandiosity; hypersexuality;
Insight or judgment - Impaired
Orientation - Confusion, delirium
Memory - can be detrimental to memory and result in coma.

Mental status
examination
(during
stimulant
withdrawal)

Behavior - Sedated
Psychomotor activity - Decreased
Mood or affect - Depressed or irritable
Speech - Decreased production
Thought processes or content - suicidal ideation and drug
craving. Homicidal ideation; paranoia
Insight or judgment - Variable
Orientation - May be normal or close to normal
Memory - Likely impaired due to sleep deprivation,
associated fatigue, decreased attention and irritability

Diagnostic Considerations

Delirium (toxic-metabolic, infectious)

Hyperthyroidism
Acute intermittent porphyria
Lysergic acid diethylamide (LSD) intoxication
Phencyclidine (PCP) intoxication
Caffeine overuse
Neuroleptic malignant syndrome
Alcohol, benzodiazepine, or barbiturate withdrawal
Anticholinergic overdose
Schizophrenia
Bipolar disorders
Anxiety disorders

Workup
Drug screens for amphetamines. Urine drug screens may be useful for
excluding other substances.
Routine evaluations (ECG and electrolyte evaluation).
Treatment & Management
Activated charcoal should be prescribed in a case of acute overdose.
Otherwise the treatment should target specific signs and symptoms
Consultation a psychiatrist
Patient and Family Education

Supportive therapy
Establish and maintain ABCs.
Decontamination with gastric lavage
Monitor vital signs and hydrate with intravenous fluids.
Withdrawal related insomnia may be treated with trazodone (75-200 mg),
hydroxyzine (25-50 mg), or diphenhydramine (50-100 mg) at bedtime.
Benzodiazepines should be avoided unless the patient is also in detox from
alcohol/benzodiazepines/opiates.
Neuroleptics may be used for the symptomatic treatment of psychosis.
Physical restraints may be required in certain cases.
an antidepressant is recommended for persistent (> a week) depressive
symptoms at a level of moderate or severe or associated with suicidal
ideation/attempts.

Amphetamine-Related
Psychiatric Disorders
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IVTR):

Amphetamine-induced anxiety disorder

Amphetamine-induced mood disorder
Amphetamine-induced psychotic disorder with delusions
Amphetamine-induced psychotic disorder with hallucinations
Amphetamine-induced sexual dysfunction
Amphetamine-induced sleep disorder
Amphetamine intoxication
Amphetamine intoxication delirium
Amphetamine withdrawal
Amphetamine-related disorder not otherwise specified

Pathophisiology

psychiatric symptoms inhibition of the dopamine transporter in the

striatum and nucleus accumbens
amphetamines induce the release of dopamine (dose-dependent manner,
low doses of amphetamines deplete large storage vesicles, and high doses
deplete small storage vesicles psychotic symptoms
Amphetamine-induced psychosis has been used as a model to support the
dopamine hypothesis of schizophrenia
Delirium caused by amphetamines may be related to the anticholinergic
activity

epidemiology
USA: dependence/abuse rise significantly during this
period, from 164,000 in 2002 to 257,000 in 2005
Drug Abuse Warning Network (DAWN), 2005:10% of all
drug-related hospital emergency department visits were
stimulant-related. 26% of all drug-related deaths in
Oklahoma City were due to methamphetamine,
people aged 20-39 years who are inclined to abuse
amphetamine derivatives at rave parties and dance
clubs.

Clinical presentation
occurred when the patient was not exposed
to amphetamines?
had a psychiatric disorder/symptoms
similar in relation to any other drug?
provides information about the
patient's in utero exposure to
medications, illicit drugs, alcohol,
pathogens, and trauma.
When?
How often?
How much?
intoxicated or in withdrawal?
attend rave parties?
recently increased his or her use or
started to binge?

Clinical presentation
intoxication

DSM-IV-TR
the patient has recently used an amphetamine or related substance
Clinically significant maladaptive behavioral or psychological changes developed
Such as:
Euphoria or affective blunting
Changes in sociability
Hypervigilance
Interpersonal sensitivity
Anxiety, tension, or anger
Stereotyped behaviors
Impaired judgment
Impaired social or occupational functioning

Two or more of the following conditions :

Tachycardia or bradycardia
Pupillary dilatation
Elevated or lowered blood pressure
Perspiration or chills
Nausea or vomiting
Evidence of weight loss
Psychomotor agitation or retardation
Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
Disorientation and memory loss, seizures, dyskinesias, dystonias, or coma
The symptoms are not due to a general medical condition, and another mental
disorder does not account for them better than amphetamine intoxication does.

Clinical presentation
withdrawal

DSM-IV-TR:
The patient has recently ceased or reduced heavy or prolonged use of amphetamines
or related substances.
A dysphoric mood and 2 or more of the following physiologic changes develop ed:
Fatigue
Vivid, unpleasant dreams
Insomnia or hypersomnia
Increased appetite
Psychomotor retardation or agitation
A complete mental status examination (hallucinations, delusions, suicide and/or
homicide, orientation, memory, and judgment)
The aforementioned symptoms cause clinically significant distress or impairment in
terms of social, occupational, or other important areas of functioning.
The symptoms are not due to a general medical condition, and another mental
disorder does not account for them better than amphetamine withdrawal does.

Clinical presentation physical

Differential diagnosis

Cannabis Compound Abuse

Cocaine-Related Psychiatric Disorders
Delirium
Depression
Hallucinogens
Hyperthyroidism
Hypothyroidism
Inhalant-Related Psychiatric Disorders
Insomnia
Opioid Abuse
Phencyclidine (PCP)-Related Psychiatric Disorders
Schizophrenia
Toxicity, Heroin
Toxicity, Mushroom
Wernicke-Korsakoff Syndrome

Work up
Laboratory test:
Finger-stick blood glucose test
CBC determination
Determination of electrolyte levels, including magnesium, amylase,
albumin, total protein, uric acid, BUN, alkaline phosphatase, and
bilirubin levels
Urinalysis
Stat urine or serum toxicology screening
Blood test for an alcohol levelif the patient appears intoxicated
HIV and rapid plasma reagin (RPR) tests
Imaging Studies neurologic impairments (+), CT / MRI: evaluating for
subarachnoid and intracranial hemorrhage

Other Tests
ECG cardiac involvement.
EEG seizure disorder.
brief psychotic rating scale (BPRS), Beck Depression Scale,
violence and suicide assessment
neuropsychological testing assess levels of psychosocial and
neurologic function to guide treatment
projective testing, such as the Rorschach test and the Thematic
Apperception Test, can help in clarifying thought disorders.
During amphetamine intoxication, MMSEcognitive change.

Treatment medical

medically stabilizing the patient's condition.

Overdose Induced emesis, lavage, or charcoal
The excretion of amphetamines can be accelerated by the use of ammonium
chloride, given either IV/PO.Amphetamine intoxication can be treated with ammonium
chloride 500 mg every 2-3 hours,
IV fluids adequate hydration.
psychotic or in danger of harming him or herself or others, a high-potency
antipsychotic, aware extrapyramidal symptoms,
Agitation benzodiazepines PO, IV, or IM. Lorazepam and chlordiazepoxide are
commonly used.
Administer naloxone (Narcan) in the event of concurrent opiate toxicity
Beta-blockers elevated blood pressure and pulse. also may be helpful with anxiety
or panic.

Psychiatric hospitalization may be necessary when psychosis, aggression,

and suicidality cannot be controlled.
If serotonin syndrome is suspected, stop all SSRI and SNRI medications.

Consultations:
Neurologist
Internal medicine specialist
Psychiatrist substance abuse treatment or further psychiatric
stabilization.
Social services: Social services coordinate outpatient services
Activity:Patients intoxicated with amphetamines are dangerous, and their
activity should be limited (eg, no driving) until their symptoms have resolved.

Follow up
Further Inpatient Care
observation (mania, severe depression, psychosis, delirium, or if he or she
is suicidal or homicidal)
delirium placed in a quiet, cool (not cold), dimly lit (not dark) room and, if
uncontrollable, placed in restraints.
Further Outpatient Care
Monitoring closely for recurring
Psychiatric follow-up care should occur within, at most, 2 weeks of the initial
evaluation ensure compliance.
consider a follow-up examination with a neurologist and an internist
complications of amphetamine abuse in the specific patient

Inpatient & Outpatient Medications

If psychosis persists after the offending substance is eliminated, use of an
atypical antipsychotic (risperidone, quetiapine, olanzapine, aripiprazole,
ziprasidone) may be considered.
Antimanic agents if mania >2 weeks.
Antidepressants can be useful if depression persists for 2 weeks after
withdrawal.
If anxiety >2 weeks, consider the use of nonbenzodiazepine drugs.
Medications such as beta-blockers, valproic acid, carbamazepine, or
gabapentin have shown promise in patients with substance abuse who also
have anxiety.
Sleep medication may help patients adjust their circadian rhythm and can be
used for approximately 1-2 weeks. (long period, go to sleep clinic)

complication

Psychosis
Depression
Anxiety disorder
Sleep disturbance
Memory impairment
Medical complications
Neurologic complications
Abuse of another or several substances
Psychosocial impairment
Affect dysregulation and aggression

Patient Education

Instruct the patient to abstain from alcohol and illicit drugs, especially
because dual diagnosis is a real issue. The only effective treatment is
abstinence.
Patients should be in a support group.
psychosocial counseling.
Hospitalize (suicidal or homicidal)
substance abuse counseling.
The family must be educated about the patient's addiction and its dangers

Thank you