eMedicine Specialties > Psychiatry > Addiction

Cocaine-Related Psychiatric Disorders

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

Introduction

Background

Cocaine is a naturally occurring alkaloid found within the leaves of a shrub, Erythroxylon coca. The earliest reported use of cocaine dates back to times when the ancient inhabitants of Peru used the leaves for religious ceremonies. Cocaine was first isolated from the coca leaf in 1859. Its first use as a local anesthetic was reported in 1884. In the late 19th century, Sigmund Freud proposed cocaine for the treatment of depression, cachexia, and asthma. It later became prescribed for almost any illness and could be found in numerous tonics. In 1885, John Styth Pemberton registered a cocaine-containing drink in the United States. This drink was later named Coca-Cola. In 1914, the Harrison Narcotics Act banned all nonprescription use of cocaine. Finally, in 1970, the Controlled Substances Act prohibited the possession of cocaine in the United States, except for limited medical uses.

Cocaine may be abused through a number of different routes. The most widespread routes of administration include inhaling (snorting), subcutaneous injection (skin popping), intravenous injection (shooting-up), and smoking (freebasing or smoking crack). Because of poor absorption and significant first-pass metabolism, cocaine is rarely ingested.

Cocaine abuse is associated with numerous detrimental health effects. All organ systems can be adversely affected by its use. Cocaine-related psychiatric disorders have been well-documented in the literature. Ten cocaine-induced psychiatric disorders are described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR )¹ . These cocaine-induced disorders include the following:

• Cocaine intoxication
• Cocaine withdrawal
• Cocaine intoxication 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
• Cocaine-related disorder not otherwise specified

For related information, see Medscape's CME course, The Dark Side of Drug Addiction.

Pathophysiology

The time to peak effects of cocaine depends on the dose and route of administration. When cocaine is injected intravenously or crack is smoked, the onset of action is within seconds and peak effects occur within 5 minutes. When snorted, the onset of action of cocaine is within the first 5 minutes and its effects typically peak within 30 minutes. Cocaine can be absorbed across any mucosal surface, including the respiratory, gastrointestinal, and genitourinary tracts.

Two major routes account for cocaine's metabolism: (1) enzymatic metabolism by both liver esterases and plasma cholinesterase to ecgonine methyl ester and (2) nonenzymatic degradation to benzoylecgonine. The half-life of cocaine is 30-90 minutes. The metabolites ecgonine methyl ester and benzoylecgonine are excreted in the urine. Drug screens detect the presence of benzoylecgonine, which may be present in the urine for 2-3 days, depending on the dose and chronicity of usage. Rare cases of benzoylecgonine detection in the urine for 22 days following cocaine use have been reported.

Cocaine has a number of pharmacologic effects on the human body. Neuronal fast sodium channel blockade produces a local anesthetic effect that continues to be used in medicine today. During myocardial fast sodium channel blockade, cocaine blocks fast cardiac sodium channels, which results in type I antidysrhythmic activity. This may lead to prolongation of the QRS complex and contribute to the induction of the dysrhythmias associated with cocaine use.

Blockade of catecholamine reuptake (ie, norepinephrine, dopamine, and serotonin reuptake blockade) occurs in both the central and peripheral nervous systems. Blockade of reuptake of norepinephrine leads to the sympathomimetic syndrome associated with cocaine use. This syndrome consists of tachycardia, hypertension, tachypnea, mydriasis, diaphoresis, and agitation. Inhibition of dopamine reuptake in the CNS synapses, such as in the nucleus accumbens, contributes to the euphoria associated with cocaine. Norepinephrine release augments norepinephrine reuptake blockade effects.

Frequency

United States

The following statistics are from the 2005 National Survey on Drug Use & Health (NSDUH) for the age group 12 years and older.²

• Approximately 33.7 million Americans have tried cocaine at least once in their lifetimes, representing 13.8% of the 12 years and older population.
• Approximately 5.5 million (2.3%) used cocaine in the past year and 2.4 million (1%) used cocaine in the past month. 
• The incidence of cocaine use generally rose throughout the 1970s to a peak in 1980 (1.7 million new users) and subsequently declined until 1991 (0.7 million new users). Cocaine initiation steadily increased during the 1990s, reaching 1.2 million in 2001.
• Within the past 12 months of the time the survey was taken, 872,000 persons used cocaine for the first time. That is a statistically significant reduction from 2002 when there were more than 1 million past-year cocaine initiates.

International

Cocaine continues to be a major drug of abuse internationally. In Mexico, for example, patients in drug abuse treatment programs in 16 cities report cocaine as the primary drug of choice.

Mortality/Morbidity

The Drug Abuse Warning Network (DAWN) reports drug-related deaths. For 2003, 122 jurisdictions in 35 metropolitan areas and 6 states submitted mortality data to DAWN.

• In drug misuse deaths, cocaine was among the top 5 drugs in 28 of the 32 metropolitan areas and in all of the 6 states.
• On average, cocaine alone or in combination with other drugs was reported in 39% of drug misuse deaths.
• The etiologies of some of the deaths associated with cocaine abuse include cardiac dysrhythmias, myocardial infarctions, intractable seizures, strokes, and aortic dissection.

Race

• In the 2005 Youth Risk Behavior Survey, Hispanic and white students  were significantly more likely than African American students to report lifetime cocaine use (12.2% and 7.7%, respectively, vs 2.3%).
• The 1999 Drug Abuse Warning Network data reported cocaine as an agent in 59%, 36%, and 35% of drug-related emergency department visits among African Americans, Hispanics, and whites, respectively.

Sex

In the 2005 National Youth Risk Behavior Survey, 8.4% of males and 6.8% of females had used cocaine at least once in 2005. According to DAWN, males are disproportionately represented among deaths related to drug misuse or abuse. After adjusting for population size, the rate of drug misuse deaths per 1,000,000 population for males was 2.4 that for females.

Age

Among students surveyed as part of the 2006 Monitoring the Future study, 3.4% of eighth graders, 4.8% of tenth graders, and 8.5% of twelfth graders reported lifetime use of cocaine. Approximately 8.8% of college students and 14.3% of young adults (aged 19-28) surveyed in 2005 reported lifetime use of cocaine.

Clinical

History

The DSM-IV-TR describes 10 cocaine-induced psychiatric disorders. A thorough history pertaining to the type of symptoms experienced by the patient and the timing of these symptoms in association with cocaine abuse is necessary to make each diagnosis. Other cocaine-induced medical problems may be present and/or coexistent with any of these 10 cocaine-induced psychiatric conditions. For example, a patient may present with specific clinical criteria that lead to the diagnosis of a cocaine-induced psychotic disorder with hallucinations. That same patient also may report chest pain, a symptom that could be associated with cocaine-induced acute coronary syndrome, pneumothorax, or pulmonary edema. The following are described in the DSM-IV-TR:

• Cocaine intoxication
  • To be diagnosed with cocaine intoxication, a patient must have used cocaine recently and must have developed clinically significant behavioral or psychological changes.
  • These changes may consist of euphoria, hypervigilance, talkativeness, grandiosity, anxiety, impaired judgment, anger, tension, changes in sociability, or changes in occupational functioning. Impaired judgment, anger, and tension can be extreme and increase the risk for violent and even homicidal behavior. In addition, the patient must demonstrate 2 or more of the following 9 signs or symptoms during or shortly after the cocaine use:
    • Tachycardia or bradycardia
    • Mydriasis
    • Blood pressure change
    • Perspiration
    • Nausea or vomiting
    • Weight loss
    • Psychomotor agitation or retardation
    • Weakness, respiratory depression, chest pain, or dysrhythmia
    • Disorientation, seizures, dyskinesias, dystonias, or coma
  • Mental status examination may show a patient who is agitated and restless with a labile affect, irritable or anxious mood, poor judgment, and impaired attention. Assess for homicidal ideation and be aware of increased risk of violence.
• Cocaine withdrawal
  • The diagnostic criteria for cocaine withdrawal include cessation or reduction in previously heavy or prolonged cocaine use.
  • The patient also must have a dysphoric mood associated with 2 of the following 5 physiological changes:
    • Fatigue
    • Vivid unpleasant dreams
    • Insomnia or hypersomnia
    • Increased appetite
    • Psychomotor agitation or retardation
  • These signs or symptoms result in significant distress in the patient clinically and may impair the patient's social or occupational areas of functioning. The patient may experience significant depressed mood with suicidal ideation.
  • Mental status examination may show a sleepy, slowed-down patient who complains of depressed mood and has a restricted affect. They may express suicidal ideation.
• Cocaine intoxication delirium
  • The diagnosis of cocaine intoxication delirium is made instead of the diagnosis of cocaine intoxication only when the cognitive symptoms are in excess of those typically encountered in cocaine intoxication. These symptoms are of such severity as to warrant independent clinical attention.
  • The diagnostic criteria of cocaine intoxication delirium include both a disturbance in consciousness resulting in a reduction of the patient's ability to focus, sustain, or shift attention and a change in cognition. These changes must develop over a short period and fluctuate in severity throughout the day.
  • Patients with delirium demonstrate impairment in their ability to receive, process, store, and recall information. They are easily distracted by irrelevant stimuli. Reasoning and problem solving is difficult. Orientation to time and place may be impaired, but orientation to person typically is intact except in the most severe cases. Cocaine-induced delirium is usually transient and reversible.
  • Evidence must show that the above changes occur during or are related to cocaine intoxication.
  • Mental status examination would show a patient who is very distractible and confused with a variable affect and mood. Visual illusions (visual misperception of stimuli) may also be present. Judgment is extremely poor, as is orientation. Although suicidal and homicidal ideation may not be present, the patient may be at risk for harm due to their poor judgment and orientation.
• Cocaine-induced psychotic disorders with delusions
  • The diagnosis of cocaine-induced psychotic disorder with delusions is made instead of a diagnosis of cocaine intoxication or withdrawal only when the psychotic symptoms are in excess of those typically encountered in intoxication or withdrawal. Delusions may be of any type but typically are paranoid and/or grandiose in nature.
  • Patients presenting with psychosis demonstrate a gross distortion of their mental capacity, communication, interactions with others, ability to recognize reality, and affective response. These distortions interfere with their ability to cope with the ordinary demands of everyday life.
  • A person demonstrating delusions clings to a false belief or judgment despite incontrovertible evidence to the contrary. For example, a female abusing cocaine may demonstrate delusions of grandeur and believe that she possesses great wealth, intellect, and power, despite the fact that she is homeless and without education. Suicidal or homicidal ideation can occur in response to delusional beliefs.
  • The diagnostic criteria for this disorder include prominent delusions developing during or within a month of cocaine intoxication or withdrawal.
  • Mental status examination often shows a guarded, tense patient who may appear fearful or anxious. They may or may not reveal their paranoid delusions and may be suspicious of questions asked. Judgment is impaired by their beliefs and may add to homicidal or suicidal ideation.
• Cocaine-induced psychotic disorders with hallucinations
  • The diagnosis of cocaine-induced psychotic disorder with hallucinations is made instead of cocaine intoxication or withdrawal only when the psychotic symptoms are in excess of those typically encountered in intoxication or withdrawal.
  • A person demonstrating hallucinations has a strong subjective perception in any sensory modality of an object or event when no such object or event is present. Auditory and tactile are the 2 types of hallucinations encountered most frequently. For example, a person may be witnessed in conversation with himself or herself and may state that he or she is talking with someone else in the room when, in fact, no one else is present. Hallucinations can contribute to suicidal or homicidal ideation; therefore, risk of harm to self or others must be assessed.
  • The diagnostic criteria for this disorder include prominent hallucinations developing during or within a month of cocaine intoxication or withdrawal.
  • Mental status examination shows a patient who is distracted by internal stimuli, may show thought blocking (verbal outflow is stopped mid thought by internal stimuli), and has a reactive affect and labile mood influenced by internal voices. Attention is variable, and homicidal and suicidal ideation may be fueled by the internal voices. 
• Cocaine-induced mood disorder
  • In cocaine-induced mood disorder, a prominent and persistent disturbance in mood that arises only in association with the abuse of cocaine must occur. The symptoms must develop during or within 1 month of cocaine use, and the use of cocaine closely corresponds to these symptoms.
  • The mood changes may be depressive, manic, or mixed (neither mania nor depression predominates). The symptoms must not be better accounted for by another mood disorder that is not induced by cocaine, must not occur only during delirium, and must cause significant impairment in areas of functioning, such as social or occupational.
  • A patient demonstrating a depressed mood may show a loss of interest in daily activities, apathy, weight changes, fatigue, feelings of worthlessness, excessive guilt, indecisiveness, diminished ability to concentrate, and/or recent thoughts of death.
  • A patient presenting with acute mania may demonstrate inflated self-esteem, decreased need for sleep, talkativeness, flight of ideas, distractibility, increased goal-directed activity, and/or irritability.
  • Mental status of the depressed mood shows a patient with restricted or flat affect, depressed mood, and slowed movements and responses. They may have reduced concentration and suicidal ideation. Orientation is intact. If manic, their affect is reactive, mood is elevated and/or irritable, speech is pressured, and thoughts are tangential. Judgment is often impaired, but orientation is intact. 
• Cocaine-induced anxiety disorder
  • To be diagnosed with cocaine-induced anxiety disorder, a patient must have prominent anxiety, panic attacks, obsessions, or compulsions. The symptoms must develop during or within 1 month of cocaine use, and the use of cocaine closely corresponds to these symptoms.
  • The symptoms must not be better accounted for by another anxiety disorder that is not induced by cocaine, must not occur only during delirium, and must cause significant impairment in areas of functioning, such as social or occupational.
  • A patient presenting with a cocaine-induced anxiety disorder demonstrates a diffuse, highly unpleasant, often vague feeling of apprehension accompanied by one or more bodily sensations, such as tightness in the chest or pounding heart.
  • Mental status examination shows a patient with a reactive affect, anxious mood, possible restlessness, and difficulty concentrating. Judgment and orientation are usually intact. Due to distress, suicidal ideation may be present.
• Cocaine-induced sexual dysfunction
  • To be diagnosed with cocaine-induced sexual dysfunction, a patient must have prominent sexual dysfunction that results in distress or interpersonal difficulty.
  • The symptoms of sexual dysfunction include impaired sexual desire, impaired arousal, impaired orgasm, or sexual pain.
  • The symptoms must develop during or within 1 month of cocaine use, and the use of cocaine closely corresponds to these symptoms. The symptoms must not be better accounted for by another sexual dysfunction that is not induced by cocaine.
• Cocaine-induced sleep disorder
  • To be diagnosed with cocaine-induced sleep disorder, a patient must have a prominent disturbance in sleep.
  • The 4 types of sleep disorder include insomnia, hypersomnia, parasomnia, and a mixed sleep disorder in which more than one sleep disturbance occurs and none predominates.
  • The symptoms must develop during or within 1 month of cocaine use, and the use of cocaine closely corresponds to these symptoms. The symptoms must not be better accounted for by another sleep disorder that is not induced by cocaine, must not occur exclusively during delirium, and must cause significant impairment in areas of functioning, such as social or occupational.
• Cocaine-related disorder not otherwise specified: This category is for disorders associated with the abuse of cocaine that are not otherwise classifiable as 1 of the 9 disorders noted above.

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).

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.

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