Amphetamine-Related Psychiatric Disorders Clinical Presentation

Amphetamine-related psychiatric disorders can be confused with psychiatric disorders caused by other organic, medical, and psychiatric etiologies. The causes of amphetamine-related psychiatric can be determined through history, physical exam, and preliminary laboratory workup. 

The DSM-5-TR provides criteria helpful for determining if the patient is in a state of intoxication or withdrawal. The criteria helps clinicians distinguish disorders occurring during intoxication (eg, psychosis, delirium, mania, anxiety, insomnia) from those occurring during withdrawal (eg, depression, hypersomnia). ^[1]

Developmental history

The developmental history provides information about the patient's in utero exposure to medications, illicit substances, pathogens, and trauma.

As children, patients may have had prodromal symptoms of psychiatric disorders, such as social isolation, deteriorating school performance, mood liability, amotivation, avolition, anhedonia, sleep disturbances, psychomotor retardation, demoralization, social isolation, and suicidal thoughts and behaviors.

Delinquency, truancy, difficulties in formal education structures, early use of illicit substances and alcohol, oppositional behavior associated with conduct disorder, and early participation in the rave party scene may predispose to the development of amphetamine-related psychiatric disorders. 

Psychiatric history

Two issues are emphasized:

• Determine whether psychiatric symptoms ever occurred prior to exposure to amphetamines. 

• Determine whether the patient ever had psychiatric symptoms similar to the present symptoms when taking other illicit substances or medications. 

Recent history

The patient's history of amphetamine use is determined by asking the following questions:

• When did the patient's amphetamine use start?

• How often does the patient use amphetamines?

• How much does he or she use?

• Via what route does he or she use (inhalational, oral, intravenous)?

• Is the patient currently intoxicated or in withdrawal from amphetamines?

• Has the patient recently increased his or her amphetamine use or started to binge?

Substance use history

Substances patients may use concurrently with amphetamines:

• Alcohol

• Marijuana

• Cocaine

• Lysergic acid diethylamide (LSD)

• OTC sympathomimetics

• Steroids

Family history

A family history of a psychiatric disorder may suggest a primary psychiatric disorder. A diagnosis of amphetamine-related psychiatric disorder might still be possible if the patient has no family history of psychiatric disorders. 

DSM criteria for intoxication and withdrawal

The DSM-5-TR criteria for stimulant intoxication are as follows:

• A. Recent use of an amphetamine-type substance, cocaine or other stimulant.

• B. Clinically significant problematic behavioral or psychological changes (eg, euphoria or affective blunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger; stereotyped behaviors; impaired judgment) that develop during, or shortly after, use of a stimulant.

• C. Two (or more) of the following signs or symptoms, developing during, or shortly after, stimulant use:

  • Tachycardia or bradycardia

  • Pupillary dilatation

  • Elevated or lowered blood pressure

  • Perspiration or chills

  • Nausea or vomiting

  • Evidence of unintentional weight loss

  • Psychomotor agitation or retardation

  • Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias

  • Confusion, seizures, dyskinesias, dystonias, or coma

• The signs or symptoms are not attributable to another medical condition, and are not better explained by another mental disorder, including intoxication with another substance.

The DSM-5-TR criteria for stimulant withdrawal are as follows:

• A. Cessation of (or reduction in) the prolonged use of an amphetamines, cocaine, or other stimulant compound. 

• B. Dysphoric mood and two (or more) of the following physiologic changes developing within a few hours to several days after Criterion A:

  • Fatigue

  • Vivid, unpleasant dreams

  • Insomnia or hypersomnia

  • Increased appetite

  • Psychomotor retardation or agitation

• The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other areas of functioning.

• The signs or symptoms are not attributable to another general medical condition, and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

A full physical, neurologic, and mental status examination should be performed. Initially assess patients for medical stability through assesment of airway, breathing, circulation, and stability of vital signs. Then, assess for degree of danger to ensure safety of yourself and other staff. 

During the physical examination, look for signs and symptoms of amphetamine use, including hyperthermia, hypertension, unintentional weight loss, tachypnea, decreased vision, mydriasis, dry mucous membranes and decreased skin turgor due to dehydration, and arrhythmias. 

During the neurologic examination, assess the patient for evidence of amphetamine use, including mydriasis, decreased vision, hyperreflexia, parasthesias, and tremors. Pay attention to concerns of headache and focal neurologic deficits as this may represent hemorrhagic stroke from stimulant use. 

The mental status exam should focus on identifying delusions, hallucinations, suicidal and homicidal ideation, and insight and judgment. The mental status examination can be very different for intoxication and psychosis.

A mental status expected for a patient with amphetamine intoxication is as follows: ^[10]

• Appearance and behavior: People using methamphetamine chronically may have low BMI, appearing malnourished, disheveled, and diaphoretic. Linear eschars and excoriations may be present near veins of the skin from IV injection. They may exhibit sporadic changes in behavior, alternating between episodes of talkative oversharing and violent behavior. 

• Speech: Increased, pressured rate

• Thought process: Tangential, circumferential 

• Thought content: Paranoid; no suicidal or homicidal thoughts

• Mood: Anxious, hypomanic

• Affect: Anxious and tense

• Insight and judgment: Poor

• Orientation: Alert to person, place, and purpose; perspective of time is disorganized

A mental status expected for a patient with amphetamine psychosis is as follows: ^[11]

• Appearance and behavior: Disheveled, suspicious, paranoid, difficult to engage,  poor eye contact

• Speech: Decreased rate, rapid

• Thought process: Disorganized, guarded and internally preoccupied

• Thought content: Paranoid; possible auditory hallucinations; may have suicidal or homicidal thoughts

• Mood: Anxious

• Affect: Paranoid and fearful

• Insight and judgment: Poor

• Orientation: Has no concept of purpose, though understands place and person; perspective of time is disorganized

A mental status for a patient withdrawing form amphetamines is as follows:

• Appearance and behavior: Disheveled, psychomotor slowing, poor eye contact, skin pallor 

• Speech: Decreased tone and volume

• Thought processes: Poverty of thought, decreased content, guarded

• Thought content: No auditory, visual hallucinations; suicidal thoughts may be present, but minimal to no homicidal thoughts

• Mood: Depressed 

• Affect: Flat and withdrawn

• Insight and judgment: Poor

• Orientation: Oriented to person, place, and purpose

Causes may include the following:

• Amphetamine intoxication, binge pattern use, and long-term exposure

• Comorbid psychiatric disorders, such as depression, psychotic disorders, and anxiety disorders

• Abuse of other substances such as alcohol, OTC sympathomimetics, and illicit drugs

• Dehydration, which can result in electrolyte imbalances and renal failure

• Potential for serotonin syndrome in those prescribed serotonin reuptake inhibitors or serotonin norepinephrine reuptake inhibitors

Complications include an increased risk of the following:

• Psychosis

• Depression

• Anxiety disorder

• Sleep disturbance

• Memory impairment

• Medical complications

• Neurologic complications

• Other comorbid substance use disorder 

• Psychosocial impairment

• Affect dysregulation and aggression ^[12]

If amphetamine use and amphetamine-related psychiatric disorders occur in the context of 1 or more personality disorders, the amphetamine-related disorder is more difficult to treat successfully.