AMPHETAMINE

-RELATED
PSYCHIATRIC
DISORDERS
MEDSCAPE
AUTHOR: AMY BARNHORST, MD;
CHIEF EDITOR: GLEN L XIONG, MD
SEP 12, 2017

JAUHAROTUL JANNAH 201710401011085

Amphetamine-induce anxiety disorder

Amphetamine-induce bipolar Amphetamine intoxication

disorder
Amphetamine-induce depressive Amphetamine
disorder intoxication delirium
Amphetamine-induce psychotic
disorder Amphetamine
Amphetamine-induce sexual withdrawl
dysfunction
Unspecified stimulant
Amphetamine-induce sleep disorder releted disorder

Amphetamine-induce OCD 2
• The dose needed to
produce toxicity and
psychiatric symptoms in
a child is as low as 2 mg.
A typical dose is 2.5-40
mg/d.
“ Prescription
• In adults, narcolepsy,
amphetamines are
ADHD of the adult type, used frequently in
and some depression children and
can be treated with adolescents to treat
amphetamines. Although
they are controlled attention deficit
substances, abuse is hyperactivity disorder
(ADHD) ”
possible, especially in
persons with alcoholism
or substance abuse.
3
 3,4-methylenedioxymethamphetamine (MDMA)

popular recreational stimulant

commonly referred to as ecstasy
The drug is often consumed in dance
euphoria, high energy, and social clubs, where users dance vigorously for
disinhibition lasting 3-6 hours long periods

The drug sometimes causes toxicity and

dehydration, as well as severe hyperthermia

para -methoxyamphetamine (PMA), 2,5-dimethoxy-4-

other amphetamine bromo amphetamine (DOB), methamphetamine (crystal
derivatives methamphetamine, crystal meth, or "Tina"), and 3,4
methylenedioxyamphetamine (MDA). 4
Amphetamine-related psychiatric disorders

conditions resulting from intoxication or long-term use of amphetamines or

amphetamine derivatives.

often self-limiting after cessation, though, in some patients, psychiatric

symptoms may last several weeks after discontinuatio

differentiated from those of related primary psychiatric disorders

symptoms
by time. If symptoms do not resolve within 2 weeks after the
amphetamines are discontinued, a primary psychiatric disorder
should be suspected. Depending on the severity of symptoms,
symptomatic treatment can be delayed to clarify the etiology.

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Amphetamine-
induced psychosis
(delusions and
hallucinations) Differentiated from
psychotic disorders
when symptoms
• Absence of first-rank resolve after
Schneiderian symptoms,
including anhedonia, amphetamines are
avolition, amotivation, and discontinued
flat affect, further suggests
amphetamine-induced
psychosis

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Amphetamine-induced delirium
• Follows a reversible course similar to other causes of delirium, and it is identified by
its relationship to amphetamine intoxication. After the delirium subsides, little to no
impairment is observed. Delirium is not a condition observed during amphetamine
withdrawal.
Mood disorders
• Similar to hypomania and mania can be elicited during intoxication with
amphetamines
• Depression can occur during withdrawal, and repeated use of amphetamines can
produce antidepressant-resistant amphetamine-induced depression.
• low-dose amphetamines can be used as an adjunct in the treatment of depression,
especially in patients with medical compromise, lethargy, hypersomnia, low energy, or
decreased attention.

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Sleep disturbances

A disrupted circadian rhythm can result from late or high doses

of prescription amphetamines or from chronic or intermittent
abuse of amphetamines.

• During intoxication, sleep can be decreased markedly

• In withdrawal, sleep often increases

Individuals who use prescription amphetamines can easily correct their sleep
disturbance by lowering the dose or taking their medication earlier in the day
than they have been.
Insomnia is the most common adverse effect of prescription amphetamines.
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Pathophysiology

Influence
amphetamine- multiple difficult to
related psychiatric neural establish
disorders systems

inhibition of the
dopamine increase in
Chronic transporter in the dopamine in induce
abuse striatum and the synaptic psychosis
nucleus cleft
accumbens

negative symptoms commonly observed in schizophrenia are relatively rare

in amphetamine psychosis. 9
 MDMA
acute release of inhibits the reuptake of
serotonin and serotonin into the
neuron
dopamine

cognitive, neurologic, and behavioral

abnormalities, as well as hyperthermia

Serotonergic damage has been

suggested to lead to cognitive
impairment.
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Delirium caused by amphetamines
• may be related to the anticholinergic activity
• Rapid eye movement during the first phase is decreased during
intoxication, and a rebound elevation of rapid eye movement
occurs during withdrawal; this effect eventually alters the
circadian rhythm and results in sleep disturbances.

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Epidemiology
• Psychosis, delirium, mood symptoms, anxiety, insomnia, and sexual
dysfunction are considered rare adverse effects of therapeutic doses of
prescription amphetamines.
• Data about the frequency of amphetamine-related psychiatric disorders are
unreliable because of comorbid primary psychiatric illnesses.
• Intravenous (IV) use occurs more frequently in people of low socioeconomic
status than in those of high socioeconomic status.
• The first amphetamine epidemic occurred after World War II in Japan, when
leftover supplies intended to counteract fatigue in pilots were made
available to the general public. This even resulted in many cases of
amphetamine psychosis.

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Mortality/Morbidity

The Drug Abuse

Warning 10% of all drug-related hospital
emergency department visits were
Network stimulant-related
(DAWN) Annual
Medical 26% of all drug-related deaths in Oklahoma City
Examiner Data were due to methamphetamine
for 2005

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 cardiovascular collapse, myocardial
HIGH DOSE infarction, stroke, seizures, renal failure,
Amphetamine ischemic colitis, and hepatotoxicity. increase
sexual arousal and disinhibition

Memory impairment can result after long-

term use of high doses of amphetamines
because of damage to serotonin-releasing
neurons.
Amphetamine withdrawal is consistent with
a major depressive episode, though lasting
less then 2 weeks and involving decreased
energy, increased appetite, craving for sleep,
and suicidal ideation
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 most commonly occur in white individuals

most commonly occur in men, with a male-

With IV
to-female ratio of 3-4:1
use
Amphetamine-
related psychiatric With
disorders non-IV occur equally in men and
use women

most frequently occur in people aged 20-39 years who

are inclined to abuse amphetamine derivatives at rave
parties and dance clubs

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History

Psychiatric
history Developmental
history Family history
•psychiatric disorder  A diagnosis of
when the patient was not patients may have amphetamine-related
had prodromal psychiatric disorder
exposed to amphetamines symptoms of might still be possible if
•psychiatric disorder  psychiatric disorders the patient has no
present symptoms in family history of
relation to any other drug or psychiatric disorder.
medication.

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History

Recent history Substance abuse history

• When did the patient's amphetamine use • Potentially abused substances include the
start? following:
• How often does the patient use • Alcohol
amphetamines? • Marijuana
• How much does he or she use? • Cocaine
• Is the patient currently intoxicated or in • Lysergic acid diethylamide (LSD)
withdrawal from amphetamines? • OTC sympathomimetics
• Does the patient frequently attend rave • Steroids
parties?
• Has the patient recently increased his or
her amphetamine use or started to binge?

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DSM Criteria for Intoxication andWithdrawal
The DSM-5 criteria for stimulant intoxication are as follows
• Recent ues of an amphetamine-type substance, cocaine or
other stimulant.
• 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.
• 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
The DSM-5 criteria for stimulant withdrawal are as follows:
• Cessation of (or reduction in) prolonged amphetamine-type
substance, cocaine, or other stimulant use.
• 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.
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Physical Examination
• Full physical and neurologic examination should be performed.
• Assess 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, andaffect. The mental
status examination can be very different for intoxication and psychosis.

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A mental status expected for a patient with amphetamine intoxication is
as follows:
• Appearance and behavior: Unusually friendly, scattered eye contact, buccal oral
gyrations, excoriations on extremities and face from picking at skin, overly talkative and
verbally intrusive
• 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

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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.
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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
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 • 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,
Causes 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
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Differential Diagnoses
Cannabis-Related Disorders Insomnia

Cocaine-Related Psychiatric Disorders

Opioid Abuse

Delirium Phencyclidine (PCP)-Related Psychiatric

Disorders
Depression
Schizophrenia
Hallucinogen Use
Toxicity, Heroin
Hyperthyroidism and Thyrotoxicosis
Toxicity, Mushroom
Hypothyroidism
Wernicke-Korsakoff Syndrome
Inhalant-Related Psychiatric Disorders
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 Laboratory

Workup Imaging

exclude complications of
amphetamine abuse and
other causes of
Other
psychosis and altered
mental status
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Laboratory Studies
• 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
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Imaging Studies
• In the presence of neurologic impairments, CT or MRI helps in evaluating for
subarachnoid and intracranial hemorrhage

Other Tests
• Perform ECG to evaluate for cardiac involvement.
• Perform EEG if a seizure disorder is considered possible.
• Use of the brief psychotic rating scale (BPRS), Beck Depression Scale, violence and suicide
assessment, and other measures may be helpful.
• If persistent psychiatric conditions are noted, neuropsychological testing can be beneficial
to assess levels of psychosocial and neurologic function to guide treatment and to assess
the need for placement.
• Results of projective testing, such as the Rorschach test and the Thematic Apperception
Test, can help in clarifying thought disorders.
• During amphetamine intoxication, the Mini-Mental State Examination (MMSE) can be
helpful in measuring cognitive change.
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Treatment

removal of the amphetamines

Treatment
assessing his or her respiratory, circulatory, and
neurologic systems
Initial

gastric lavage and acidification of the urine

Psychotropic medication can be used to stabilize

an agitated patient with psychosis

Induced emesis, lavage, or charcoal may be

helpful in the event of overdose
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Amphetamine intoxication can be treated with ammonium chloride, often found in
OTC expectorants,suchasammonium

• 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.

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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.

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.

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Consultations
• Consultations with a neurologist, internal medicine specialist,
psychiatrist, or social services may prove helpful.
• Consult a psychiatrist for inpatient substance abuse treatment or
further psychiatric stabilization.
• Social services coordinate outpatient services, such as Alcoholics
Anonymous and Narcotics Anonymous meetings and sober
houses, and provide appointments. Some large metropolitan areas
have groups that specifically focus on crystal methamphetamine
abuse in the gay population.

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Patients intoxicated with
amphetamines are
Activity
dangerous, and their
activity should be limited
(eg, no driving) until their
symptoms have resolved.

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Follow-up

Admit the patient for observation in the event of mania, severe

depression, psychosis, delirium, or if he or she is suicidal or
In Patient homicidal.
A patient who is in a state of delirium should be placed in a quiet,
cool (not cold), dimly lit (not dark) room and, if uncontrollable,
placed in restraints.

should be monitored closely for recurring psychosis, depression, mania,

anxiety, sleep disturbances, and relapse of amphetamine abuse.
Psychiatric follow-up care should occur within, at most, 2 weeks of the
Out Patient initial evaluation to ensure compliance.
Depending on the complications of amphetamine abuse in the specific
patient, consider a follow-up examination with a neurologist and an
internal medicine specialist.
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Complications

Psychosis Medical complications

Depression Neurologic complications

Abuse of another or several

Anxiety disorder substances

Sleep disturbance Psychosocial impairment

Affect dysregulation and

Memory impairment aggression
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 PROGNOSIS
• The patient's prognosis
depends on the severity of
psychiatric impairment and
on the medical complications.
• Overall, the prognosis is good
if the patient abstains from
drug use after the initial
psychiatric impairment
occurs.
• The prognosis worsens if
personality disorders are
present.
Patient Education
• Instruct the patient to abstain from alcohol and illicit drugs, especially
because dual diagnosis is a real issue. The only effective treatment is
abstinence.
• Patients should be in a support group.
• The family must be educated about the patient's addiction and its dangers.
• Refer the patient for psychosocial counseling.
• Hospitalize the patient if he or she is suicidal or homicidal.
• Refer the patient for substance abuse counseling.

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THANK YOU