eMedicine Specialties > Psychiatry > Addiction

Inhalant-Related Psychiatric Disorders

Author: Guy E Brannon, MD, Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company
Coauthor(s): Jeanie McGee Gary, BS, Editorial Manager, Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport
Contributor Information and Disclosures

Updated: Feb 5, 2008

Introduction

Background

Inhalant-related psychiatric disorders are a heterogenous group of illnesses caused by the abuse of solvents, glues, paint, fuels, or other volatile substances.

Although huffing, as it is commonly referred to, has existed since ancient times, it has regained popularity in recent years. The resurgence of this newfound phenomenon is believed to be due to a number of variables (eg, low cost, availability, peer influence, rapid mood-elevating quality), which have made this potentially fatal activity popular among many young people today. A relationship may exist between inhalant use and an increased risk of frequent drinking, binge-type drinking, smoking, and the use of other drugs, making inhalant-related disorders a new public health problem deserving of more attention.

Because most of the products used in huffing are legal household products, they are easily accessible and are relatively inexpensive to obtain. Most recent reports state that nearly 1000 such products are available to huffers every day. Some of the most common products used for inhaling are spray paint (containing butane, lead, or propane), permanent markers, correction fluid (eg, Liquid Paper, Wite-Out), glue (containing toluene or ethyl acetate), lighter fluid (containing butane or isopropane), hairspray (containing butane or propane), propane, gasoline (containing lead), kerosene, and nitrous oxide from a balloon. Because of the increase in awareness of the potential dangers caused by sniffing or inhaling, laws have been established that prohibit the sale of certain products to minors; however, enforcing these laws is difficult.

Generally, adolescents practice huffing; however, younger children and young adults also engage in this potentially fatal act. Huffing involves placing the volatile substance (most commonly some type of chemical, eg, butane found in spray paint, acetone found in nail polish remover) on a rag or in a closed container (eg, soda can, plastic bag [termed "bagging"]), placing the rag over the nose and mouth, and breathing deeply to cause mood-altering effects.

The inhalation of these substances can cause permanent organ damage and death. Huffing is a problem in the United States and abroad, and it accounts for a large portion of emergency department visits. Diagnosis of inhalant-related psychiatric disorders is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR)¹ or International Classification of Diseases, 10th Revision criteria.

Although studies have shown that inhalant abuse has been difficult to diagnose, treatment efforts for inhalant-related psychiatric disorders may be promising. Treatment consists of psychotherapy (eg, 12-step programs similar to Alcoholics Anonymous, cognitive behavior therapy, rational-emotive therapy) and pharmacotherapy. Early intervention may play a key role because engagement in this activity may lead to the use of other drugs.

Pathophysiology

Inhalants are CNS depressants (similar to alcohol) and are thought to influence gamma-aminobutyric acid (GABA), although the exact mechanism has yet to be determined. No evidence associates inhalants with the opiate system; N -methyl-D-aspartate may play a role.

Medical effects

• Brain: Most of the damage inflicted by inhalant abuse initially affects the brain.  Tremors and uncontrollable shaking are observed in those who abuse inhalants for a long period. Inhalants also affect eyesight, causing double vision and other sight disorders. Many who abuse inhalants experience seizures. Headaches are common. Those who abuse toluene may have significantly wider cerebellar and cerebral sulci and larger ventricular systems.
• Lungs: Repeated use of inhalants can cause lung damage, including hypoxia, sinus discharge, coughing, cyanosis, and upper and lower airway irritation.
• Heart: Heart problems can occur, including irregular heartbeat and sudden sniffing death syndrome, which is heart failure resulting from an irregular heartbeat.
• Gastrointestinal: Problems include abdominal pain, nausea, and vomiting.
• Liver: Liver function can actually shut down, either temporarily or permanently, depending on length and extent of inhalant use (ie, cirrhosis).
• Kidney: Kidney stones and complete loss of kidney function can develop.
• Muscle: Long-term inhalant abuse leads to muscle weakness, muscle wasting, and reduced muscle tone and strength.
• Bone marrow: Inhalants damage bone marrow. In addition, the chemical benzene, which is found in gasoline, has been shown to cause leukemia.
• Peripheral nervous system: Damage from inhalants can cause temporary numbness, permanent nerve damage, permanent paralysis, or generalized weakness, depending on the frequency of abuse.
• Hearing: Some who abuse inhalants become deaf because of the inhalation of chemicals that destroy cells that relay sound to the brain.
• Other medical effects: Other effects of inhalant abuse include respiratory problems, asphyxiation, aeration, and fetal damage similar to that observed in patients with fetal alcohol syndrome.

Psychiatric effects

The psychiatric effects of inhalant abuse include impaired judgment, confusion, fright, hyperactivity, anxiety, acute psychosis, increased violence and aggressive behavior, depression, organic brain syndrome (ie, coarse tremor, staggering gait, speech problems, thought disorder), abuse, tolerance and dependence, hallucinations, decreased intelligence quotient, intoxication, mood disorder, dementia, and withdrawal. Inhalant abuse also affects social, educational, and economic status. In addition, persons who abuse inhalants are more likely to be involved in accidents (eg, falls, burns, frostbite). Importantly, note that the number of planned suicides in persons with inhalant-related psychiatric disorders is equal to the number of planned suicides in persons with other psychiatric illnesses; however, the number of unplanned suicides is dramatically higher in children and adolescents who engage in huffing.

Frequency

United States

Of the population, 6% have tried huffing once and 1% are current users. According to statistics gathered by the National Inhalant Prevention Coalition, ". . . by the time a student reaches the eighth grade, 1 in 5 will have used inhalants."² Inhalants account for 1% of substance-induced death. Huffing is more common in rural versus inner-city adolescents, although exact numbers are difficult to determine.

International

Incidents occur worldwide, but determining exact numbers is difficult.

Mortality/Morbidity

Inhalants work quickly by passing through the nasal cavity and entering the lungs, bloodstream, and brain, all in a matter of seconds. The chemical vapors of the inhalants are dissolved into the fatty tissues of the brain. The results of inhalant abuse affect virtually every organ and function of the body, including the brain, heart, lungs, kidneys, muscle, bone marrow, and peripheral and central nervous systems, to name a few. Persons who abuse inhalants long-term may become permanently disabled, losing their ability to walk, talk, and think. The possible damage depends on the chemical used, the frequency with which it is used, and the amount used.

Race

Persons who abuse inhalants predominantly are white; however, studies have found minority involvement in subcultures of American and Canadian Indians and in Hispanic persons with low-income status. Inhalant use is more common in rural and suburban areas than in urban areas.

Sex

Although long-term inhalant use is more common in males than in females, experimental use is equally common in males and females.

Age

Experimental use of inhalants normally occurs in late childhood and early adolescence (age 9-13 y). Long-term use appears during early and late adolescence (age 12-17 y). Inhalants are commonly the first substance used before the onset of substance (eg, tobacco, alcohol, marijuana, cocaine) abuse occurs. Inhalant abuse among younger children and adults is less frequent, although it does occur.

Clinical

History

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.

Physical

• 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

Causes

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.

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