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Amphetamine-Related Psychiatric Disorders Clinical Presentation

  • Author: Amy Barnhorst, MD; Chief Editor: Eduardo Dunayevich, MD  more...
 
Updated: Dec 03, 2015
 

History

Amphetamine-related psychiatric disorders can be confused with psychiatric disorders caused by organic, medical, neurologic, and/or psychological etiologies. The causes of amphetamine-related psychiatric disorders usually can be determined by assessing the patient's history and the family's genealogy.

The DSM-5 provides criteria helpful for determining if the patient is in a state of intoxication or withdrawal. The criteria helps clinicians distinguish disorders occurring during intoxication (eg, psychosis, delirium, mania, anxiety, insomnia) from those occurring during withdrawal (eg, depression, hypersomnia).

Developmental history

The developmental history provides information about the patient's in utero exposure to medications, illicit drugs, alcohol, pathogens, and trauma.

As children, patients may have had prodromal symptoms of psychiatric disorders, such as social isolation, deteriorating school performance, mood liability, amotivation, avolition, anhedonia, sleep disturbances, sexual paraphilias, poor interest, psychomotor retardation, demoralization, social isolation, and suicidal thoughts and behaviors.

Delinquency, truancy, educational failure, early use of drugs and alcohol, oppositional behavior associated with conduct disorder, and participation in the rave party scene are developmental behaviors that suggest an amphetamine-related psychiatric disorder.

Psychiatric history

Two issues are emphasized:

  • Determine whether a psychiatric disorder or symptoms ever occurred when the patient was not exposed to amphetamines.
  • Determine whether the patient ever had a psychiatric disorder or symptoms similar to the present symptoms in relation to any other drug or medication.

Recent history

The patient's history of amphetamine abuse is the most important factor and is determined by asking the following questions:

  • When did the patient's amphetamine use start?
  • How often does the patient use amphetamines?
  • How much does he or she use?
  • Is the patient currently intoxicated or in withdrawal from amphetamines?
  • Does the patient frequently attend rave parties?
  • Has the patient recently increased his or her amphetamine use or started to binge?

Substance abuse history

Potentially abused substances include the following:

  • Alcohol
  • Marijuana
  • Cocaine
  • Lysergic acid diethylamide (LSD)
  • OTC sympathomimetics
  • Steroids

Family history

A family history of a psychiatric disorder may suggest a primary psychiatric disorder. A diagnosis of amphetamine-related psychiatric disorder might still be possible if the patient has no family history of psychiatric disorder.

DSM criteria for intoxication and withdrawal

The DSM-5 criteria for stimulant intoxication are as follows:

  • A. Recent ues of an amphetamine-type substance, cocaine or other stimulant.
  • B. Clinically significant problematic behavioral or psychological changes (e.g., euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment) that develop during, or shortly after, use of a stimulant.
  • C. Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use:
    • 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
    • Confusion, seizures, dyskinesias, dystonias, or coma
  • The signs or symptoms are not attributable to another medical condition, and are not better explained by another mental disorder, including intoxication with another substance.

The DSM-5 criteria for stimulant withdrawal are as follows:

  • A. Cessation of (or reduction in) prolonged amphetamine-type substance, cocaine, or other stimulant use.
  • B. Dysphoric mood and two (or more)  of the following physiologic changes developing within a few hours to several days after Criterion A:
    • Fatigue
    • Vivid, unpleasant dreams
    • Insomnia or hypersomnia
    • Increased appetite
    • Psychomotor retardation or agitation
  • The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The signs or symptoms are not attributable to another general medical condition, and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.
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Physical

Full physical and neurologic examination should be performed. Initially assess patients for medical stability and then for level of danger.

During physical examination, assess the patient for medical complications of amphetamine abuse, including hyperthermia, dehydration, renal failure, and cardiac complications.

During neurologic examination, assess the patient for neurologic complications of amphetamine abuse, including subarachnoid and intracranial hemorrhage, delirium, and seizures.

Mental status examination should emphasize delusions, hallucinations, suicide, homicide, orientation, insight and judgment, and affect. The mental status examination can be very different for intoxication and psychosis.

A mental status expected for a patient with amphetamine intoxication is as follows:

  • Appearance and behavior: Unusually friendly, scattered eye contact, buccal oral gyrations, excoriations on extremities and face from picking at skin, overly talkative and verbally intrusive [8]
  • Speech: Increased rate
  • Thought process: Tangential, circumstantial over inclusive and disinhibited
  • Thought content: Paranoid; no suicidal or homicidal thoughts
  • Mood: Anxious, hypomanic
  • Affect: Anxious and tense
  • Insight and judgment: Poor
  • Orientation: Alert to person, place, and purpose; perspective of time is disorganized

A mental status expected for a patient with amphetamine psychosis is as follows:[9, 10]

  • Appearance and behavior: Disheveled, suspicious, paranoid, difficult to engage, and poor eye contact
  • Speech: Decreased and rapid
  • Thought process: Guarded and internally preoccupied
  • Thought content: Paranoid; possible auditory hallucinations; no suicidal or homicidal thoughts
  • Mood: Anxious
  • Affect: Paranoid and fearful
  • Insight and judgment: Poor
  • Orientation: Has no concept of purpose, though understands place and person; perspective of time is disorganized.

A mental status for a patient withdrawing form amphetamines is as follows:

  • Appearance and behavior: Disheveled, psychomotor slowing, poor eye contact, pale appearance to skin
  • Speech: Decreased tone and volume
  • Thought processes: Decreased content, guarded
  • Thought content: No auditory, visual hallucinations; suicidal thoughts present, but no homicidal thoughts
  • Mood: depressed
  • Affect: Flat and withdrawn
  • Insight and judgment: Poor
  • Orientation: Oriented to person, place, and purpose
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Causes

Causes may include the following:

  • Amphetamine intoxication, binge pattern use, and long-term exposure
  • Comorbid psychiatric disorders, such as depression, psychotic disorders, and anxiety disorders
  • Abuse of other substances such as alcohol, OTC sympathomimetics, and illicit drugs
  • Dehydration, which can result in electrolyte imbalances and renal failure
  • Potential for serotonin syndrome in those prescribed serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors
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Contributor Information and Disclosures
Author

Amy Barnhorst, MD Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, Medical Center; Medical Director of Crisis Services, County of Sacramento

Amy Barnhorst, MD is a member of the following medical societies: Association for Academic Psychiatry, California Medical Association, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Received royalty from Lippincott Williams & Wilkins for book editor; Received grant/research funds from National Alliance for Research in Schizophrenia and Depression for independent contractor; Received consulting fee from Blue Cross Blue Shield Association for consulting. for: Received book royalty from American Psychiatric Publishing Inc.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Eduardo Dunayevich, MD Executive Director, Clinical Development, Amgen

Eduardo Dunayevich, MD is a member of the following medical societies: Schizophrenia International Research Society

Disclosure: Received salary from Amgen for employment; Received stock from Amgen for employment.

Additional Contributors

Michael F Larson, DO Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard Medical School; Psychiatrist, Harvard Vanguard Medical Associates and Private Practice

Michael F Larson, DO is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Society of Addiction Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael F Larson, DO Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard Medical School; Psychiatrist, Harvard Vanguard Medical Associates and Private Practice

Michael F Larson, DO is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, and American Society of Addiction Medicine

Disclosure: Nothing to disclose.

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