Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Cocaine-Related Psychiatric Disorders Clinical Presentation

  • Author: Christopher P Holstege, MD; Chief Editor: David Bienenfeld, MD  more...
 
Updated: Apr 14, 2016
 

History

Diagnostic Criteria (DSM-5)

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies cocaine use under the category of stimulant-related disorders. The five disorders now recognized are as follows:[1]

  • Stimulant use disorder
  • Stimulant intoxication
  • Stimulant withdrawal
  • Other stimulant-induced disorders
  • Unspecified stimulant-related disorder 

Stimulant use disorder

Symptoms of stimulant use disorders include craving for stimulants, failure to control use when attempted, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, spending a great deal of time to obtain and use stimulants, and withdrawal symptoms that occur after stopping or reducing use, including fatigue, vivid and unpleasant dreams, sleep problems, increased appetite, or irregular problems in controlling movement.[1]

Stimulant intoxication

Criteria for stimulant intoxication are as follows:[1]

  • Recent use of an amphetamine-type substance, cocaine, or other stimulant.
  • Clinically significant problematic behavioral or psychological changes that developed during, or shortly after, use of stimulant.
  • Two or more of the following signs or symptoms:
    • Tachycardia or bradycardia
    • Pupillary dilation
    • 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, seizure, dyskinesias, dystonias, or coma

Stimulant withdrawal

Withdrawal manifests after cessation or reduction of prolonged use of cocaine and results in a dysphoric mood and two (or more) of the following changes:[1]

  • Fatigue
  • Vivid, unpleasant dreams
  • Insomnia or hypersomnia
  • Increased appetite
  • Psychomotor retardation or agitation

These signs usually cause clinically significant distress or impairment and are not attributable to another medical condition or disorder.

Next

Physical

Cocaine affects multiple organ systems. A thorough physical examination must be performed on patients suspected of cocaine abuse.

Vital signs

Acute cocaine intoxication is most commonly associated with tachycardia and hypertension due to an induced sympathomimetic syndrome.

Any patient presenting with a history of cocaine abuse and altered mental status must have an adequate temperature taken, preferably a core temperature, such as rectal. Hyperthermia associated with acute cocaine toxicity must be closely monitored.

Tachypnea may be simply a result of cocaine's stimulant effects. However, other etiologies of tachypnea include pulmonary edema, pneumothorax, pulmonary embolism, acute coronary syndrome, panic attacks, and withdrawal syndromes.

Skin and extremities

Acute cocaine toxicity is typically associated with diaphoresis.

The skin may be cool as a result of the vasoconstrictive effects of cocaine, despite an elevated core temperature.

Examine the skin for evidence of intravenous (track marks) or subcutaneous (skin popping) drug abuse.

Head, ears, eyes, nose, and throat

Close inspection of the head for signs such as edema, ecchymosis, or bony deformity is necessary to help exclude the possibility of head trauma.

Examine the eyes for pupil size (mydriasis with acute cocaine abuse), presence of nystagmus, and extraocular muscle function.

Individuals who chronically abuse cocaine who insufflate cocaine may have nasal septa perforations as a result of necrosis from repetitive cocaine-induced vasoconstriction and subsequent ischemia.

Cardiovascular

Heart sounds may reveal murmurs (endocarditis and/or valvular damage), rubs (pericarditis), or dysrhythmias.

Pulmonary

Rales due to pulmonary edema (cardiac and noncardiac etiologies associated with cocaine), pneumonia (infectious or aspiration), or atelectasis (pulmonary embolism) may be present.

Decreased breath sounds may be noted as a result of a pneumothorax.

Acute bronchospasm (wheezing) may be noted secondary to smoking crack cocaine or cocaine insufflation abuse.

Gastrointestinal: Vomiting, diarrhea, and hyperactive bowel sounds may be noted with acute cocaine abuse.

Neurologic

People who abuse cocaine may present with seizures, agitation, tremor, and hyperreflexia.

Focal muscular weakness or sensory changes may occur secondary to cerebral vascular accident.

Psychiatric

The American Psychiatric Association recognizes a number of cocaine-induced psychiatric conditions.

Patients may present with delirium, psychosis, delusions, hallucinations, depression, mania, and anxiety (see History).

Previous
Next

Causes

Numerous potential causes and risks factors have been cited as associated with cocaine abuse.

  • The US National Institute on Drug Abuse estimates that approximately 10% of people who begin to use cocaine progress to heavy, chronic abuse.
  • A family history of substance abuse directly correlates both with the development of cocaine abuse and with earlier age of onset of cocaine abuse.
  • Approximately 50% of those who abuse illicit drugs also have a co-occurring mental disorder.
  • For example, individuals who abuse cocaine have higher rates of antisocial personality disorder, depression, anxiety, and attention-deficit/hyperactivity disorder.
  • Low levels of family bonding and high levels of peer antisocial activity were consistently associated with higher prevalence of illicit drug initiation among youths aged 12-21.
Previous
 
 
Contributor Information and Disclosures
Author

Christopher P Holstege, MD Professor of Emergency Medicine and Pediatrics, University of Virginia School of Medicine; Chief, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Center

Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, Medical Society of Virginia, Society of Toxicology, Wilderness Medical Society, European Association of Poisons Centres and Clinical Toxicologists, American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Lori Holstege, MD Assistant Clinical Professor, Department of Psychiatry, Michigan State University

Lori Holstege, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Nathan P Charlton, MD Fellow in Medical Toxicology, University of Virginia, Blue Ridge Poison Center

Nathan P Charlton, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, South Carolina Medical Association, Wilderness Medical Society, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

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

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Barry I Liskow, MD Professor of Psychiatry, Vice Chairman, Psychiatry Department, Director, Psychiatric Outpatient Clinic, The University of Kansas Medical Center

Disclosure: Nothing to disclose.

References
  1. American Psychiatric Association. Substance-Related and Addictive Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 561-570.

  2. Center for Behavioral Health Statistics and Quality. Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. SAMHSA. Available at http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. September 2015;

  3. Lopez-Quintero C, Cobos JP, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. 2011 May 1. 115(1-2):120-30. [Medline]. [Full Text].

  4. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. The DAWN Report: Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits. Substance Abuse and Mental Health Services Administration. Available at http://www.samhsa.gov/data/sites/default/files/DAWN127/DAWN127/sr127-DAWN-highlights.htm. February 22, 2013;

  5. Kann L, Kinchen S, Shanklin SL, Flint KH, Kawkins J, Harris WA, et al. Youth risk behavior surveillance--United States, 2013. MMWR Surveill Summ. 2014 Jun 13. 63 Suppl 4:1-168. [Medline].

  6. Johnston, L. D., O’Malley, P. M., Miech, R. A., et al. Monitoring the Future national survey results on drug use: 1975-2014: Overview, key findings on adolescent drug use. monitoringthefuture.org. Available at http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2014.pdf. 2015; Accessed: December 3, 2015.

  7. Martinez D, Carpenter KM, Liu F, et al. Imaging dopamine transmission in cocaine dependence: link between neurochemistry and response to treatment. Am J Psychiatry. 2011 Jun. 168(6):634-41. [Medline].

  8. Morgan PT, Pace-Schott E, Pittman B, Stickgold R, Malison RT. Normalizing effects of modafinil on sleep in chronic cocaine users. Am J Psychiatry. 2010 Mar. 167(3):331-40. [Medline].

  9. Martell BA, Orson FM, Poling J, Mitchell E, Rossen RD, Gardner T, et al. Cocaine vaccine for the treatment of cocaine dependence in methadone-maintained patients: a randomized, double-blind, placebo-controlled efficacy trial. Arch Gen Psychiatry. 2009 Oct. 66(10):1116-23. [Medline].

  10. von Diemen L, Kapczinski F, Sordi AO, de Magalhães Narvaez JC, Guimarães LS, Kessler FH, et al. Increase in brain-derived neurotrophic factor expression in early crack cocaine withdrawal. Int J Neuropsychopharmacol. 2013 Sep 26. 1-8. [Medline].

  11. Ní Chróinín D, Gaine S. Crack-ing the case: a patient with persistent delirium due to body packing with cocaine. Ir Med J. 2012 Apr. 105(4):118-9. [Medline].

  12. Corominas-Roso M, Roncero C, Eiroa-Orosa FJ, Ribasés M, Barral C, Daigre C, et al. Serum Brain-Derived Neurotrophic Factor Levels and Cocaine-Induced Transient Psychotic Symptoms. Neuropsychobiology. 2013 Sep 13. 68(3):146-155. [Medline].

  13. Roncero C, Ros-Cucurull E, Daigre C, Casas M. Prevalence and risk factors of psychotic symptoms in cocaine-dependent patients. Actas Esp Psiquiatr. 2012 Jul-Aug. 40(4):187-97. [Medline].

  14. Abraham HD, Fava M. Order of onset of substance abuse and depression in a sample of depressed outpatients. Compr Psychiatry. 1999 Jan-Feb. 40(1):44-50. [Medline].

  15. Back S, Dansky BS, Coffey SF, et al. Cocaine dependence with and without post-traumatic stress disorder: a comparison of substance use, trauma history and psychiatric comorbidity. Am J Addict. 2000 Winter. 9(1):51-62. [Medline].

  16. Biggins CA, MacKay S, Clark W, Fein G. Event-related potential evidence for frontal cortex effects of chronic cocaine dependence. Biol Psychiatry. 1997 Sep 15. 42(6):472-85. [Medline].

  17. Blanchard DC, Blanchard RJ. Cocaine potentiates defensive behaviors related to fear and anxiety. Neurosci Biobehav Rev. 1999 Nov. 23(7):981-91. [Medline].

  18. Bolla KI, Rothman R, Cadet JL. Dose-related neurobehavioral effects of chronic cocaine use. J Neuropsychiatry Clin Neurosci. 1999 Summer. 11(3):361-9. [Medline].

  19. Cacciola JS, Alterman AI, O'Brien CP, McLellan AT. The Addiction Severity Index in clinical efficacy trials of medications for cocaine dependence. NIDA Res Monogr. 1997. 175:182-91. [Medline].

  20. Crits-Christoph P, Siqueland L, Blaine J, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry. 1999 Jun. 56(6):493-502. [Medline].

  21. Cubells JF, Feinn R, Pearson D. Rating the severity and character of transient cocaine-induced delusions and hallucinations with a new instrument, the Scale for Assessment of Positive Symptoms for Cocaine-Induced Psychosis (SAPS-CIP). Drug Alcohol Depend. 2005. May 12:[Medline].

  22. Franken IH, Kroon LY, Hendriks VM. Influence of individual differences in craving and obsessive cocaine thoughts on attentional processes in cocaine abuse patients. Addict Behav. 2000 Jan-Feb. 25(1):99-102. [Medline].

  23. Garbett R. National vocational qualifications?. NT Learn Curve. 1997 May 7. 1(3):15. [Medline].

  24. Gingrich JA, Rudnick-Levin F, Almeida C, et al. Cocaine and catatonia. Am J Psychiatry. 1998 Nov. 155(11):1629. [Medline].

  25. Goldfrank LR, Flomenbaum NE, Lewin NA. Cocaine. Goldfrank L, Flomenbaum N, Levin N, Weisman R, Hawland M, Hoffman R, eds. Goldfrank's Toxicologic Emergencies. 6th ed. Stamford, Conn: Appleton & Lange; 1998. 1071-89.

  26. Harris D, Batki SL. Stimulant psychosis: symptom profile and acute clinical course. Am J Addict. 2000 Winter. 9(1):28-37. [Medline].

  27. Havassy BE, Arns PG. Relationship of cocaine and other substance dependence to well-being of high-risk psychiatric patients. Psychiatr Serv. 1998 Jul. 49(7):935-40. [Medline].

  28. Herning RI, King DE, Better WE, Cadet JL. Neurovascular deficits in cocaine abusers. Neuropsychopharmacology. 1999 Jul. 21(1):110-8. [Medline].

  29. Hollander JE, Todd KH, Green G, et al. Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments. Ann Emerg Med. 1995 Dec. 26(6):671-6. [Medline].

  30. Hyman SE. A 28-year-old man addicted to cocaine. JAMA. 2001 Nov 28. 286(20):2586-94. [Medline].

  31. Jones RT. Pharmacokinetics of cocaine: considerations when assessing cocaine use by urinalysis. NIDA Res Monogr. 1997. 175:221-34. [Medline].

  32. Kampman, K. New Medications for the Treatment of Cocaine Dependence. Psychiatry. December 2005. 2:44-48. [Full Text].

  33. Karlsgodt KH, Lukas SE, Elman I. Psychosocial stress and the duration of cocaine use in non-treatment seeking individuals with cocaine dependence. Am J Drug Alcohol Abuse. 2003 Aug. 29(3):539-51. [Medline].

  34. Levin FR, Evans SM, Coomaraswammy S, et al. Flupenthixol treatment for cocaine abusers with schizophrenia: a pilot study. Am J Drug Alcohol Abuse. 1998 Aug. 24(3):343-60. [Medline].

  35. Levin FR, Evans SM, Kleber HD. Prevalence of adult attention-deficit hyperactivity disorder among cocaine abusers seeking treatment. Drug Alcohol Depend. 1998 Sep 1. 52(1):15-25. [Medline].

  36. Levin FR, Evans SM, McDowell DM, Kleber HD. Methylphenidate treatment for cocaine abusers with adult attention- deficit/hyperactivity disorder: a pilot study. J Clin Psychiatry. 1998 Jun. 59(6):300-5. [Medline].

  37. Lima MS, Reisser AA, Soares BG, Farrell M. Antidepressants for cocaine dependence. Cochrane Database Syst Rev. 2003. CD002950. [Medline].

  38. Mann A. Relationships Matter: Impact of Parental, Peer Factors on Teen, Young Adult Substance Abuse. National Institute on Drug Abuse. Available at www.nida.nih.gov/NIDA-notes/NNVol18. Accessed: 5/22/2008.

  39. McCance-Katz EF, Kosten TR, Jatlow P. Concurrent use of cocaine and alcohol is more potent and potentially more toxic than use of either alone--a multiple-dose study. Biol Psychiatry. 1998 Aug 15. 44(4):250-9. [Medline].

  40. McDowell DM, Levin FR, Seracini AM, Nunes EV. Venlafaxine treatment of cocaine abusers with depressive disorders. Am J Drug Alcohol Abuse. 2000 Feb. 26(1):25-31. [Medline].

  41. McKay JR, Alterman AI, Cacciola JS, et al. Prognostic significance of antisocial personality disorder in cocaine- dependent patients entering continuing care. J Nerv Ment Dis. 2000 May. 188(5):287-96. [Medline].

  42. McMahon RC, Malow R, Loewinger L. Substance abuse history predicts depression and relapse status among cocaine abusers. Am J Addict. 1999 Winter. 8(1):1-8. [Medline].

  43. Mueser KT, Yarnold PR, Rosenberg SD, et al. Substance use disorder in hospitalized severely mentally ill psychiatric patients: prevalence, correlates, and subgroups. Schizophr Bull. 2000. 26(1):179-92. [Medline].

  44. Pettinati H. New Pharmacotherapies for Treating the Neurobiology of Alcohol and Drug Addiction. Psychiatry. May 2006. 3:14-16. [Full Text].

  45. Rivara FP, Mueller BA, Somes G, et al. Alcohol and illicit drug abuse and the risk of violent death in the home. JAMA. 1997 Aug 20. 278(7):569-75. [Medline].

  46. Rutherford MJ, Cacciola JS, Alterman AI. Antisocial personality disorder and psychopathy in cocaine-dependent women. Am J Psychiatry. 1999 Jun. 156(6):849-56. [Medline].

  47. Schubiner H, Tzelepis A, Milberger S, et al. Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among substance abusers. J Clin Psychiatry. 2000 Apr. 61(4):244-51. [Medline].

  48. Serper MR, Chou JC, Allen MH, et al. Symptomatic overlap of cocaine intoxication and acute schizophrenia at emergency presentation. Schizophr Bull. 1999. 25(2):387-94. [Medline].

  49. Serper MR, Copersino ML, Richarme D, et al. Neurocognitive functioning in recently abstinent, cocaine-abusing schizophrenic patients. J Subst Abuse. 2000. 11(2):205-13. [Medline].

  50. Siqueland L, Horn A, Moras K, et al. Cocaine-induced mood disorder: prevalence rates and psychiatric symptoms in an outpatient cocaine-dependent sample. Am J Addict. 1999 Spring. 8(2):165-9. [Medline].

  51. Soares BG, Lima MS, Reisser AA, Farrell M. Dopamine agonists for cocaine dependence. Cochrane Database Syst Rev. 2003. CD003352. [Medline].

  52. Sofuoglu M, Dudish-Poulsen S, Brown SB, Hatsukami DK. Association of cocaine withdrawal symptoms with more severe dependence and enhanced subjective response to cocaine. Drug Alcohol Depend. 2003 Apr 1. 69(3):273-82. [Medline].

  53. Work Group on Substance Use Disorders. Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd edition. Am J Psychiatry Suppl. April 2007. 164:72-75.

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.