Amphetamine-Related Psychiatric Disorders Clinical Presentation

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-IV-TR 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.
• The DSM-IV-TR criteria for amphetamine intoxication are as follows:

  • The patient has recently used an amphetamine or related substance, such as methylphenidate.
  • Clinically significant maladaptive behavioral or psychological changes developed during or shortly after the patient used amphetamines or a related substance. Such changes include the following:
    • 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 develop during or shortly after the patient used amphetamines or a related substance:
    • 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.
• The DSM-IV-TR criteria for amphetamine withdrawal are as follows:

  • 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 within a few hours to several days after the patient ceases or reduces his or her use:
    • Fatigue
    • Vivid, unpleasant dreams
    • Insomnia or hypersomnia
    • Increased appetite
    • Psychomotor retardation or agitation
  • A complete mental status examination must be performed, with an emphasis on 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.

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
  • 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:

  • 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

• 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