MENTAL DISORDER DUE TO STIMULANT

Jurnal Reading
Intan Kinanti
201520401011144
 Stimulants are substances that induce a number of
characteristic symptoms. CNS effects include
alertness with increased vigilance, a sense of well-
being, and euphoria. Many users experience
insomnia and anorexia, and some may develop
psychotic symptoms.
 Definition

A clinically significant behavioral or psychological syndrome or

pattern that occurs in an individual and that is associated with
present distress or disability or with a significantly increased
risk of suffering death, pain, disability or an important loss of
freedom.
Symptoms of Mental Illness

Perceptions

Thoughts

Moods

Behavior
Substance-Related Disorders
Types of Disorder Substances
o Alcohol
Substance-induced o Amphetamines
o Caffeine
Intoxication o Cannabis
Withdrawal o Cocaine
o Hallucinogens
Various psychiatric o Inhalants
symptoms o Nicotine
o Opioids
Substance Use o Phencyclidine
Dependence o Sedative-hypnotics
o Polysubstance
Abuse
Epidemiology
Data about the frequency of amphetamine-related
psychiatric disorders are unreliable because of comorbid
primary psychiatric illnesses.
In 2013, an estimated 144,000 people became new users
of methamphetamine, which is consistent with the new
user initation rates of the preceding five years.
Pathophysiology
The pathophysiology of amphetamine-related psychiatric disorders is
difficult to establish, because amphetamines influence multiple neural
systems.

In general, chronic amphetamine abuse may cause psychiatric

symptoms due to inhibition of the dopamine transporter in the
striatum and nucleus accumbens.

The longer the duration of use, the greater the magnitude

of dopamine reduction.

Methamphetamine has been suggested to induce

psychosis through inhibiting the dopamine transporter, with
a resultant increase in dopamine in the synaptic cleft.
Pathophysiology

This increase in dopaminergic activity may be causally related to

psychotic symptoms because the use of D2-blocking agents (eg,
haloperidol) often ameliorates these symptoms.

Amphetamine-induced psychosis has been used as a model to support the

dopamine hypothesis of schizophrenia, in which overactivity of dopamine in the
limbic system and striatum is associated with psychosis.
Pathophysiology

MDMA causes the acute release of serotonin and dopamine and inhibits the
reuptake of serotonin into the neuron.

MDMA use is associated with cognitive, neurologic, and behavioral

abnormalities, as well as hyperthermia,

Serotonergic damage has been suggested to lead to cognitive impairment.

DSM criteria for intoxication and withdrawal

The DSM-5 criteria for stimulant intoxication

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

B. Clinically significant problematic behavioral or psychological changes (e.g., 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 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.
DSM criteria for intoxication and withdrawal

The DSM-5 criteria for stimulant withdrawal

A. Cessation of (or reduction in) prolonged amphetamine-type substance,

cocaine, or other stimulant use.

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 important 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.
Physical

During physical examination, assess During neurologic examination,

the patient for medical complications
of amphetamine abuse, including
hyperthermia, dehydration, renal
failure, and cardiac
complications.
assess the patient for neurologic
complications of amphetamine
abuse, including subarachnoid and
intracranial hemorrhage, delirium,
and seizures.

Mental status examination should

emphasize delusions,
hallucinations, suicide, homicide,
orientation, insight and judgment,
and affect. 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:

Appearance and behavior: Unusually friendly, scattered eye contact, excoriations on

extremities and face from picking at skin, overly talkative and verbally intrusive [8]
Speech: Increased rate
Thought process: Tangential, circumstantial over inclusive and disinhibited
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:
Appearance and behavior: Disheveled, suspicious, paranoid, difficult to engage, and poor
eye contact
Speech: Decreased and rapid
Thought process: Guarded and internally preoccupied
Thought content: Paranoid; possible auditory hallucinations; no 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, pale appearance to skin
Speech: Decreased tone and volume
Thought processes: Decreased content, guarded
Thought content: No auditory, visual hallucinations; suicidal thoughts
present, but no homicidal thoughts
Mood: depressed
Affect: Flat and withdrawn
Insight and judgment: Poor
Orientation: Oriented to person, place, and purpose
Causes
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
Differential Diagnoses
Cannabis-Related Disorders
Cocaine-Related Psychiatric Disorders
Delirium
Depression
Hallucinogen Use
Hyperthyroidism
Hypothyroidism
Inhalant-Related Psychiatric Disorders
Insomnia
Opioid Abuse
Phencyclidine (PCP)-Related Psychiatric Disorders
Schizophrenia
Toxicity, Heroin
Toxicity, Mushroom
Wernicke-Korsakoff Syndrome
Laboratory Studies
Laboratory evaluation should include the following tests:

Finger-stick blood glucose test

CBC determination

Determination of electrolyte levels, including magnesium, amylase, albumin, total protein, uric acid, BUN,
alkaline phosphatase, and bilirubin levels

Urinalysis

Stat urine or serum toxicology screening to exclude acetaminophen, tricyclic antidepressants, aspirin, and
other potential toxins: Individuals who abuse drugs may ingest a substance called Urine Luck, or
pyridinium chlorochromate (PCC), to produce invalid results on urine drug screens. PCC alters the results
for cannabis and opiates but elevates levels of amphetamines.

Blood test for an alcohol level if the patient appears intoxicated

HIV and rapid plasma reagin (RPR) tests

Imaging Studies

In the presence of neurologic impairments, CT or MRI helps in evaluating for

subarachnoid and intracranial hemorrhage.
 Medical Care
Initial treatment should include medically stabilizing the patient's condition by assessing his
or her respiratory, circulatory, and neurologic systems. The offending substance may be
eliminated by means of gastric lavage and acidification of the urine. Psychotropic
medication can be used to stabilize an agitated patient with psychosis. Because most cases
of amphetamine-related psychiatric disorders are self-limiting, removal of the
amphetamines should suffice.

Induced emesis, lavage, or charcoal may be helpful in the event of overdose.

Medical Care
The excretion of amphetamines can be accelerated by the use of ammonium chloride, given either IV or orally
(PO) :

Amphetamine intoxication can be treated with ammonium chloride, often found in OTC expectorants, such
as ammonium chloride (Quelidrine), baby cough syrup, Romilar, and P-V-Tussin.

The recommended dose to acidify the urine is ammonium chloride 500 mg every 2-3 hours.

The ingredients in OTC cough syrups vary, and the clinician should become familiar with 1 or 2 stock items
for use in the emergency department.

Ammonium chloride (Quelidrine), an OTC expectorant, can be used in the absence of liver or kidney
failure.

Administer IV fluids to provide adequate hydration.

 Medical Care
If the patient is psychotic or if he or she is in danger of harming him or herself or others, a high-potency
antipsychotic, such as haloperidol (Haldol), can be used. Exercise caution because of the potential for
extrapyramidal symptoms, such as acute dystonic reactions, and neuroleptic malignant syndrome.
Agitation also can be treated cautiously with benzodiazepines PO, IV, or intramuscularly (IM).
Lorazepam (Ativan) and chlordiazepoxide (Librium) are commonly used.
Administer naloxone (Narcan) in the event of concurrent opiate toxicity. Use caution to avoid precipitation
of acute opioid withdrawal in a patient who has used high doses of opioid on a long-term basis.
Beta-blockers, such as propranolol (Inderal), can be used in the event of elevated blood pressure and
pulse. They also may be helpful with anxiety or panic.
Psychiatric hospitalization may be necessary when psychosis, aggression, and suicidality cannot be
controlled in a less restrictive environment.
If serotonin syndrome is suspected, stop all SSRI and SNRI medications.
References

Barnhorst Amy, et al. 2015. Amphetamine-Related Psychiatric Disorders.

http://emedicine.medscape.com/article/289973-overview. Diakses pada tanggal
26 Mei 2016.
Jacob L. Freedman, M.D., and Ken Duckworth, M.D., March 2013. Stimulant Abuse
& Mental Illness. www.nami.org