Inhalant-Related Psychiatric Disorders Clinical Presentation

Persons who abuse inhalants commonly share characteristics that may help identify them as users. While taking the patient's history, determine their diagnosis based on the DSM-IV-TR criteria for inhalant abuse, inhalant dependence, inhalant intoxication, substance intoxication delirium, substance-induced persistent dementia, substance-induced psychotic disorder, substance-induced mood disorder, substance-induced anxiety disorder, and inhalant-related disorder not otherwise specified (NOS). Pay close attention to the signs and symptoms commonly associated with persons who abuse inhalants (see below). Inquire about other drugs of abuse and a family history of drug and alcohol abuse or addiction. The diagnosis is based solely on the history and a very high index of suspicion.

• Signs and symptoms

  • Chemical smell or odor on breath or body
  • Redness, sores, or spots around the lips or mouth
  • Redness of eyes
  • Runny or red nose
  • Paint stains on clothing or body
  • Nausea or loss of appetite
  • Drunken or dazed appearance
  • Dizziness
  • Irritability, excitability, or anxiety
  • Slow verbal responses in conversation
  • Sudden behavior change
  • Sensitivity to light
  • Sore or irritated throat
  • Rashes or redness on hands
• Characteristics of persons who abuse inhalants

  • Delinquency
  • Theft and burglary
  • Poor school attendance
  • Frequent suspension and expulsion from school
  • Social outcast
  • Impoverished families or middle-to-upper income status
  • Lack of parental control or guidance
  • Attention deficit
  • Poor academic performance
  • Antisocial personality
  • Depressive disorders
  • Emotional problems (specifically anxiety, depression, and anger)
  • Low self-esteem
  • Peer pressure with drug influence
• Criteria for inhalant abuse, adapted from the DSM-IV-TR

  • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 (or more) of the following, occurring within a 12-month period:
    • Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home
    • Recurrent substance use in situations in which it is physically hazardous
    • Recurrent substance-related legal problems
    • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
  • Symptoms never meeting criteria for substance dependence for this class of substance
• Criteria for inhalant dependence, adapted from the DSM-IV-TR - A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period:

  • Tolerance
    • A need for markedly increased amounts of the substance to achieve intoxication or desired effects
    • Markedly diminished effects with continued use of the same amount of the substance
  • Withdrawal
    • Characteristic withdrawal syndrome for the substance
    • Same (or a closely related) substance taken to relieve or avoid withdrawal symptoms
  • Substance often taken in larger amounts or over longer periods than was intended
  • A persistent desire or unsuccessful effort to reduce or control substance use
  • Significant time spent in activities necessary to obtain the substance or recover from its effects
  • Important social, occupational, or recreational activities are abandoned or reduced because of the substance use
  • Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
• Criteria for inhalant intoxication, adapted from the DSM-IV-TR

  • Recent intentional use or short-term high-dose exposure to volatile inhalants
  • Clinically maladaptive behavioral or psychological changes that developed during or shortly after use of or exposure to volatile inhalants
  • Two (or more) of the following signs developing during or shortly after inhalant use or exposure:
    • Dizziness
    • Nystagmus
    • Incoordination
    • Slurred speech
    • Unsteady gait
    • Lethargy
    • Depressed reflexes
    • Psychomotor retardation
    • Tremor
    • Generalized muscle weakness
    • Blurred vision or diplopia
    • Stupor or coma
    • Euphoria
  • Symptoms not due to a general medical condition and not better accounted for by another mental disorder
• Criteria for substance intoxication delirium, adapted from the DSM-IV-TR

  • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
  • A change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia
  • Disturbance occurs over a short period and tends to fluctuate during the course of the day
  • Evidence from the history, physical examination, or laboratory findings of either of the following:
    • Symptoms of (1) disturbance of consciousness with reduced ability to focus, sustain, or shift attention or (2) a change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia that developed during substance intoxication
    • Medication use etiologically related to the disturbance
• Criteria for substance-induced persistent dementia, adapted from the DSM-IV-TR

  • Development of multiple cognitive deficits manifested by both (1) memory impairment and (2) one (or more) of the following cognitive disturbances:
    • Aphasia
    • Apraxia
    • Agnosia
    • Disturbance in executive functioning
  • Cognitive deficit in (1) memory impairment and (2) aphasia, apraxia, agnosia, or disturbance in executive functioning each cause significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning
  • Deficients do not occur exclusively during the course of a delirium and persist beyond the usual duration of substance intoxication or withdrawal
  • Evidence from history, physical examination, or laboratory findings that deficits are etiologically related to the persistent effects of substance use
• Criteria for substance-induced psychotic disorder, adapted from the DSM-IV-TR

  • Prominent hallucinations or delusion
  • Evidence from history, physical examination, or laboratory findings of either of the following:
    • Symptoms of prominent hallucinations or delusion developing during or within 1 month of substance intoxication or withdrawal
    • Medication use etiologically related to the disturbance
  • Disturbance not better accounted for by a psychotic disorder that is not substance induced
  • Disturbance does not occur exclusively during the course of a delirium
• Criteria for substance-induced mood disorder, adapted from the DSM-IV-TR

  • Prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:
    • Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities
    • Elevated, expansive, or irritable mood
  • Evidence from history, physical examination, or laboratory findings of substance intoxication or withdrawal and the symptoms of (1) depressed mood or markedly diminished interest or pleasure in activities and (2) elevated, expansive, or irritable mood developing during or within 1 month of substance intoxication or withdrawal
  • Disturbance not better accounted for by mood disorder that is not substance induced
  • Disturbance does not occur exclusively during the course of a delirium
  • Disturbance causes clinically significant distress or impairment in social, occupational, or other important area of functioning
• Criteria for substance-induced anxiety disorder, adapted from the DSM-IV-TR

  • Prominent anxiety, panic attacks, obsession, or compulsion predominating in the clinical picture
  • Evidence from history, physical examination, or laboratory findings of either of the following:
    • Symptoms of prominent anxiety, panic attacks, obsession, or compulsion developing during or within 1 month of substance intoxication or withdrawal
    • Medication use etiologically related to the disturbance
  • Disturbance not better accounted for by an anxiety disorder that is not substance induced
  • Disturbance not occurring exclusively during the course of a delirium
  • Disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
• Criteria for inhalant-related disorder NOS, adapted from the DSM-IV-TR: The inhalant-related disorder NOS category is for disorders associated with the use of inhalants that are not classified as inhalant dependence, inhalant abuse, inhalant intoxication, inhalant intoxication delirium, inhalant-induced persistent dementia, inhalant-induced psychotic disorder, inhalant-induced mood disorder, or inhalant-induced anxiety disorder.

• See Lab Studies; however, no specific laboratory results confirm this diagnosis.
• Perform a detailed neurological evaluation to look for the following:

  • Apathy
  • Impaired judgment
  • Impulsiveness
  • Aggressive behavior
  • Anorexia
  • Nystagmus
  • Depressed reflexes
  • Altered levels of consciousness
  • Disinhibited behaviors
• In addition, be aware of the signs and symptoms of inhalant abuse when performing the physical examination; for example, look for the following:

  • Amnesia
  • Rashes (particularly around the hand, nose, and mouth, ie, glue-sniffer's rash)
  • Unusual breath odors (eg, chemical smells)
  • Red or irritated eyes, throat, lungs, and nose
  • Burns

Much speculation exists on the cause of inhalant abuse. Its popularity appears to be based on the fact that the substances are easily accessible to young people. The products used are fairly easy to hide, fairly inexpensive, easily attainable, and, for the most part, legal. Therefore, inhalants are readily becoming the drugs of choice. Many adolescents are becoming interested in the instant gratification huffing offers, while others engage in huffing merely because their friends are doing it. However, one subgroup of young people who abuse inhalants do so because they have seen their parents or older siblings abuse illegal drugs, and these young people have decided that huffing is the activity they choose to begin their drug use and addiction.