eMedicine Specialties > Psychiatry > Addiction

Cocaine-Related Psychiatric Disorders: Differential Diagnoses & Workup

Author: Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health
Coauthor(s): Lori Holstege, MD, Assistant Clinical Professor, Department of Psychiatry, Michigan State University; Nathan P Charlton, MD, Fellow in Medical Toxicology, University of Virginia, Blue Ridge Poison Center
Contributor Information and Disclosures

Updated: May 28, 2008

Differential Diagnoses

Amphetamine-Related Psychiatric Disorders
Panic Disorder
Anxiety Disorders
Phencyclidine (PCP)-Related Psychiatric Disorders
Attention Deficit Hyperactivity Disorder
Schizoaffective Disorder
Bipolar Affective Disorder
Schizophrenia
Delirium
Schizophreniform Disorder
Delusional Disorder
Sleep Disorders
Depression
Hallucinogens

Other Problems to Be Considered

Thyrotoxicosis
Major depressive disorder (agitated) with psychotic features

Workup

Laboratory Studies

  • When caring for patients with suspected cocaine-induced psychiatric disorders, a number of laboratory studies may be considered. For example, a patient with marked agitation with or without psychotic features may have complications from cocaine intoxication, such as rhabdomyolysis, myocardial infarction, or renal failure. The need for specific laboratory and ancillary tests noted below will vary depending on the clinical scenario.
  • Electrolytes
    • Typically, hypokalemia occurs in acute cocaine intoxication from intracellular shifts of potassium ions. This corrects as the intoxication resolves. In severe cocaine toxicity, hyperkalemia may develop and lead to cardiac dysrhythmias. The exact etiology of this is unclear, but rhabdomyolysis may be a contributing factor.
    • Metabolic acidosis (a decreased serum bicarbonate level) also may be observed in acute cocaine intoxication. This also corrects as the toxicity resolves. A progressively worsening metabolic acidosis associated with progressive altered mental status is a poor prognostic sign. Closely monitor these patients.
  • Glucose: In any patient presenting with altered mental status, obtain a rapid glucose determination to rule out hypoglycemia.
  • Renal function tests: Renal failure due to rhabdomyolysis and renal artery thrombosis has been reported with cocaine abuse.
  • Creatine kinase: This test may help diagnose rhabdomyolysis.
  • Urinalysis: If an agitated patient shows a urine-dip test result that is positive for blood but microscopic analysis reveals no red blood cells, consider urine myoglobin and rhabdomyolysis as the cause.
  • Pregnancy test: All women of childbearing age should receive a pregnancy test.
  • Liver function tests: Hepatic damage may occur in the acutely intoxicated patient. In addition, patients who use cocaine are at risk for infectious hepatitis, which also may result in acute mental status changes.
  • Complete blood cell count: Anemia, leukocytosis, and leukopenia all may lead the clinician to consider other disease entities.
  • Toxicology
    • Urine drug screens: Benzoylecgonine, a metabolite of cocaine, may be present in the urine for 60 hours after a single use of cocaine. In heavy cocaine use, it has been found in the urine as much as 22 days after cessation of cocaine use. Positive screen results are typically verified with gas chromatography with mass spectrometry.
    • Plasma cocaine levels: Because cocaine has a short half-life of 30-45 minutes and the metabolites are present in the urine for a much longer period, plasma cocaine levels typically are not as helpful as the tests that analyze for cocaine metabolites in the urine.
  • Cardiac enzymes: Because of the significant prevalence of myocardial infarction associated with cocaine use, patients presenting with chest pain and cocaine abuse should be considered candidates for cardiac enzyme monitoring.

Imaging Studies

  • Chest radiographs: Chest radiographs should be obtained in patients exhibiting pulmonary signs or symptoms after cocaine use. Pneumomediastinum, pneumothorax, pneumonia, pulmonary embolism, atelectasis, and other air-space diseases have been reported with cocaine use.
  • Head CT scan: Patients exhibiting acute mental status changes or focal neurological signs and symptoms may require a head CT scan. Cocaine use has been associated with intracranial bleeding and embolic and thrombotic strokes.

Other Tests

  • Arterial blood gas determination: This test may be useful in patients with either marked tachypnea or a decreased serum bicarbonate level to further delineate the etiology.
  • ECG: An ECG should be obtained if an individual who abuses cocaine reports chest pain, shortness of breath, syncope, or palpitations. Cocaine-induced myocardial ischemia, infarction, and dysrhythmias have been reported.
    • Cocaine is a known fast sodium channel blocker of cardiac myocytes. This can lead to a delay in the upstroke of phase 1 of depolarization and subsequent widening of the QRS duration.
    • Cocaine can cause either myocardial ischemia or infarction. This can subsequently lead to ST depression or elevation depending on the ischemia/infarct region. However, many young patients who abuse cocaine have a baseline J-point elevation that may be difficult to differentiate from an infarct pattern. In addition, normal ECG findings do not rule out the possibility of myocardial injury in a patient who abuses cocaine who has chest pain.
    • Acute cocaine toxicity also may result in hyperkalemia. This can lead to a diffuse peaking of T waves, widening of the QRS, loss of P waves, or, in the most severe cases, a sinusoidal wave pattern.

More on Cocaine-Related Psychiatric Disorders

Overview: Cocaine-Related Psychiatric Disorders
Differential Diagnoses & Workup: Cocaine-Related Psychiatric Disorders
Treatment & Medication: Cocaine-Related Psychiatric Disorders
Follow-up: Cocaine-Related Psychiatric Disorders
References
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References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.

  2. US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health. Rockville, Md: Office of Applied Studies; 2002. [Full Text].

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

  4. 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. Winter 2000;9(1):51-62. [Medline].

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

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

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

  8. 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].

  9. 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. Jun 1999;56(6):493-502. [Medline].

  10. 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].

  11. 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. Jan-Feb 2000;25(1):99-102. [Medline].

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

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

  14. Goldfrank LR, Flomenbaum NE, Lewin NA. Cocaine. In: 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.

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

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

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

  18. 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. Dec 1995;26(6):671-6. [Medline].

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

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

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

  22. 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. Aug 2003;29(3):539-51. [Medline].

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

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

  25. 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. Jun 1998;59(6):300-5. [Medline].

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

  27. 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.

  28. 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. Aug 15 1998;44(4):250-9. [Medline].

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

  30. 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. May 2000;188(5):287-96. [Medline].

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

  32. 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].

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

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

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

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

  37. 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].

  38. 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].

  39. 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. Spring 1999;8(2):165-9. [Medline].

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

  41. 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. Apr 1 2003;69(3):273-82. [Medline].

  42. 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.

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Further Reading

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Keywords

cocaine, coke, crack, psychosis, delirium, anxiety, withdrawal, Erythroxylon coca, E coca, coca leaf, coca plant, cocaine addiction, cocaine abuse, drug abuse, drug addiction, addiction, drugs, drug-related psychosis, drug-related psychiatric disorder, cocaine intoxication, cocaine withdrawal, cocaine delirium, cocaine-induced psychotic disorder with delusions, cocaine-induced psychotic disorder with hallucinations, cocaine-induced mood disorder, cocaine-induced anxiety disorder, cocaine-induced sexual dysfunction, cocaine-induced sleep disorder

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Contributor Information and Disclosures

Author

Christopher P Holstege, MD, Associate Professor of Emergency Medicine and Pediatrics, University of Virginia; Director, Division of Medical Toxicology, Center of Clinical Toxicology; Medical Director, Blue Ridge Poison Ctr, Associate Medical Toxicology Fellowship Director, VA Dept of Health
Christopher P Holstege, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Association for the Advancement of Science, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Medical Society of Virginia, Society for Academic Emergency Medicine, Society of Toxicology, and Wilderness Medical Society
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, Emergency Medicine Residents Association, South Carolina Medical Association, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Barry I Liskow, MD, Vice Chairman, Director Psychiatry Residency Program, Professor, Department of Psychiatry, University of Kansas Medical School
Barry I Liskow, MD is a member of the following medical societies: American Academy of Addiction Psychiatry
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David Bienenfeld, MD, Vice-Chair, Program Director, Professor, Department of Psychiatry, Wright State University School of Medicine
David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry
Disclosure: Nothing to disclose.

CME Editor

Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other; Pfizer Honoraria Speaking and teaching

Chief Editor

Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration and American Psychosomatic Society
Disclosure: Nothing to disclose.

 
 
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