Stimulant psychosis

Stimulant psychosis
Classification and external resources
Specialty psychiatry
ICD-10 F14.5 & F15.5
ICD-9-CM 292.1

Stimulant psychosis is a psychosis symptom which typically occurs following an overdose on psychostimulants, but it also occurs in approximately 0.1% of individuals within the first several weeks after starting amphetamine or methylphenidate therapy.[1][2][3]

The most common causative agents are substituted amphetamines and cocaine.

Signs and symptoms

The symptoms of stimulant psychosis may vary slightly depending on the drug ingested but generally include the symptoms of organic psychosis including hallucinations, delusions, and thought disorder.[1][2][3]

Stimulants known to cause psychosis

Substituted amphetamines

Drugs in the class of amphetamines, or substituted amphetamines, are known to induce "amphetamine psychosis" typically when chronically abused or used in high doses.[4] In an Australian study of 309 active methamphetamine users, 18% had experienced a clinical level psychosis in the past year.[5] The amphetamine molecule consists of a phenethylamine core with a methyl group attached to the alpha carbon. The substituted amphetamines consist of the same structure with one or more substitutions. Common examples include cathinone, DOM, ephedrine, MDMA, methamphetamine, and methcathinone though a large number of such compounds have been synthesized. Methylphenidate is sometimes incorrectly included in this class.

The symptoms of amphetamine psychosis include auditory and visual hallucinations, delusions of persecution, and delusions of reference concurrent with both clear consciousness and prominent extreme agitation.[6][7] A Japanese study of recovery from methamphetamine psychosis reported a 64% recovery rate within 10 days rising to an 82% recovery rate at 30 days after methamphetamine cessation.[8] However it has been suggested that around 5–15% of users fail to make a complete recovery in the long term.[9] Furthermore, even at a small dose, the psychosis can be quickly reestablished.[8] Psychosocial stress has been found to be an independent risk factor for psychosis relapse even without further substituted amphetamine use in certain cases.[10]

The symptoms of acute amphetamine psychosis are very similar to those of the acute phase of schizophrenia[4] although in amphetamine psychosis visual hallucinations are more common and thought disorder is rare.[11] Amphetamine psychosis may be purely related to high drug usage, or high drug usage may trigger an underlying vulnerability to schizophrenia.[4] There is some evidence that vulnerability to amphetamine psychosis and schizophrenia may be genetically related. Relatives of methamphetamine users with a history of amphetamine psychosis are five times more likely to have been diagnosed with schizophrenia than relatives of methamphetamine users without a history of amphetamine psychosis.[12] The disorders are often distinguished by a rapid resolution of symptoms in amphetamine psychosis, while schizophrenia is more likely to follow a chronic course.[13]

Although rare and not formally recognized,[14][15] a condition known as Amphetamine Withdrawal Psychosis (AWP) may occur upon cessation of substituted amphetamine use and, as the name implies, involves psychosis that appears on withdrawal from substituted amphetamines. However, unlike similar disorders, in AWP, substituted amphetamines reduce rather than increase symptoms, and the psychosis or mania resolves with resumption of the previous dosing schedule.[16]

Cocaine

Cocaine has a similar potential to induce temporary psychosis[17] with more than half of cocaine abusers reporting at least some psychotic symptoms at some point.[18] Typical symptoms of sufferers include paranoid delusions that they are being followed and that their drug use is being watched accompanied by hallucinations that support the delusional beliefs.[18] Delusional parasitosis with formication ("cocaine bugs") is also a fairly common symptom.[19]

Cocaine-induced psychosis shows sensitization toward the psychotic effects of the drug. This means that psychosis becomes more severe with repeated intermittent use.[18][20]

Methylphenidate

Chronic abuse of methylphenidate can also lead to psychosis.[21][22] The safety profile of short-term methylphenidate therapy has been well-established, with short-term clinical trials revealing a very low incidence (0.1%) of methylphenidate-induced psychosis at therapeutic dose levels.[23] Psychotic symptoms from methylphenidate can include hearing voices, visual hallucinations, urges to harm oneself, severe anxiety, mania, grandiosity, paranoid delusions, confusion, increased aggression, and irritability.

Caffeine

There is limited evidence that caffeine, in high doses or when chronically abused, may induce psychosis in normal individuals and worsen pre-existing psychosis in those diagnosed with schizophrenia.[24][25][26]

Treatment

Treatment consists of supportive care during the acute intoxication phase: maintaining hydration, body temperature, blood pressure, and heart rate at acceptable levels until the drug is sufficiently metabolized to allow vital signs to return to baseline. Typical and atypical antipsychotics have been shown to be helpful in the early stages of treatment.[4] This is followed by abstinence from psychostimulants supported with counseling or medication designed to assist the individual preventing a relapse and the resumption of a psychotic state.

Distinction from excited delirium

Though less common than stimulant psychosis, stimulants such as cocaine and amphetamines as well as the dissociative drug phencyclidine (PCP, angel dust) can also cause a severe and life-threatening condition known as excited delirium. This condition manifests as a combination of delirium, psychomotor agitation, anxiety, delusions, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature, and superhuman strength.[27] Despite some superficial similarities in presentation excited delirium is a distinct (and more serious) condition than stimulant psychosis.

See also

References

  1. 1 2 "Adderall XR Prescribing Information" (PDF). United States Food and Drug Administration. Shire US Inc. December 2013. Retrieved 30 December 2013. Treatment-emergent psychotic or manic symptoms, e.g., hallucinations, delusional thinking, or mania in children and adolescents without prior history of psychotic illness or mania can be caused by stimulants at usual doses. ... In a pooled analysis of multiple short-term, placebo controlled studies, such symptoms occurred in about 0.1% (4 patients with events out of 3482 exposed to methylphenidate or amphetamine for several weeks at usual doses) of stimulant-treated patients compared to 0 in placebo-treated patients.
  2. 1 2 Shoptaw SJ, Kao U, Ling W (January 2009). Shoptaw SJ, Ali R, ed. "Treatment for amphetamine psychosis". Cochrane Database Syst. Rev. (1): CD003026. doi:10.1002/14651858.CD003026.pub3. PMID 19160215. A minority of individuals who use amphetamines develop full-blown psychosis requiring care at emergency departments or psychiatric hospitals. In such cases, symptoms of amphetamine psychosis commonly include paranoid and persecutory delusions as well as auditory and visual hallucinations in the presence of extreme agitation. More common (about 18%) is for frequent amphetamine users to report psychotic symptoms that are sub-clinical and that do not require high-intensity intervention ...
    About 5–15% of the users who develop an amphetamine psychosis fail to recover completely (Hofmann 1983) ...
    Findings from one trial indicate use of antipsychotic medications effectively resolves symptoms of acute amphetamine psychosis.
  3. 1 2 Mosholder AD, Gelperin K, Hammad TA, Phelan K, Johann-Liang R (February 2009). "Hallucinations and other psychotic symptoms associated with the use of attention-deficit/hyperactivity disorder drugs in children". Pediatrics 123 (2): 611–616. doi:10.1542/peds.2008-0185. PMID 19171629.
  4. 1 2 3 4 Shoptaw SJ, Kao U, Ling W. "Treatment for amphetamine psychosis (Review)". Cochrane Database of Systematic Reviews 2009: 1.
  5. ↑ McKetin R, McLaren J, Lubman DI, Hides L. The prevalence of psychotic symptoms among methamphetamine users. Addiction 2006;101(10):1473–8.
  6. ↑ Dore G, Sweeting M (2006). "Drug-induced psychosis associated with crystalline methamphetamine". Australasian Psychiatry 14 (1): 86–9. doi:10.1080/j.1440-1665.2006.02252.x.
  7. ↑ Srisurapanont M, Ali R, Marsden J, Sunga A, Wada K, Monteiro M (2003). "Psychotic symptoms in methamphetamine psychotic in-patients". International Journal of Neuropsychopharmacology 6 (4): 347–52. doi:10.1017/s1461145703003675.
  8. 1 2 Sato M, Numachi Y, Hamamura T (1992). "Relapse of paranoid psychotic state in methamphetamine model of schizophrenia". Schizophrenia Bulletin 18 (1): 115–22. doi:10.1093/schbul/18.1.115.
  9. ↑ Hofmann FG (1983). A Handbook on Drug and Alcohol Abuse: The Biomedical Aspects (2nd ed.). New York: Oxford University Press. p. 329.
  10. ↑ Yui K, Ikemoto S, Goto K (2002). "Factors for susceptibility to episode recurrence in spontaneous recurrence of methamphetamine psychosis". Annals of the New York Academy of Sciences 965: 292–304. doi:10.1111/j.1749-6632.2002.tb04171.x.
  11. ↑ Alan F. Schatzberg, Charles B. Nemeroff (2009). The American Psychiatric Publishing Textbook of Psychopharmacology. The American Psychiatric Publishing. pp. 847–48. ISBN 978-1-58562-309-9.
  12. ↑ Chen CK, Lin SK, Pak CS, Ball D, Loh EW, Murray RM (2005). "Morbid risk for psychiatric disorder among the relatives of methamphetamine users with and without psychosis". American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics 136 (1): 87–91. doi:10.1002/ajmg.b.30187.
  13. ↑ McIver C, McGregor C, Baigent M, Spain D, Newcombe D, Ali R. Guidelines for the medical management of patients with methamphetamine-induced psychosis. Drug and Alcohol Services: South Australia 2006.
  14. ↑ Sarampote CS, Efron LA, Robb AS, Pearl PL, Stein MA (2002). "Can stimulant rebound mimic pediatric bipolar disorder?". J Child Adolesc Psychopharmacol 12 (1): 63–7. doi:10.1089/10445460252943588. PMID 12014597.
  15. ↑ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.
  16. ↑ Hegerl U, Sander C, Olbrich S, Schoenknecht P (Aug 2006). "Are psychostimulants a treatment option in mania?". Prog Neuropsychopharmacol Biol Psychiatry 30 (6): 1097–102.
  17. ↑ Brady KT, Lydiard RB, Malcolm R, Ballenger JC (1991). "Cocaine-induced psychosis". J Clin Psychiatry 52: 509–512.
  18. 1 2 3 Thirthalli J., Vivek B. (2006). "Psychosis Among Substance Users". Curr Opin Psychiatry 19 (3): 239–245. doi:10.1097/01.yco.0000218593.08313.fd.
  19. ↑ Elliott A., Mahmood T., Smalligan R. D. (2012). "Cocaine Bugs: A Case Report of Cocaine-Induced Delusions of Parasitosis". The American Journal on Addictions 21: 180–181. doi:10.1111/j.1521-0391.2011.00208.x.
  20. ↑ DiSCLAFANI; et al. (1981). "Drug-induced psychosis: Emergency diagnosis and management". Psychosomatics 22 (10): 845–855. doi:10.1016/s0033-3182(81)73092-5.
  21. ↑ Morton WA, Stockton GG (2000). "Methylphenidate abuse and psychiatric side effects". Prim Care Companion J Clin Psychiatry 2: 159–64. doi:10.4088/pcc.v02n0502.
  22. ↑ Spensley J, Rockwell D (April 1972). "Psychosis during Methylphenidate Abuse". New England Journal of Medicine 286: 880–1. doi:10.1056/NEJM197204202861607.
  23. ↑ "Ritalin & Ritalin-SR Prescribing Information" (PDF). Novartis. April 2007.
  24. ↑ Hedges, D. W.; F. L. Woon; S. P. Hoopes (September 2009). "Caffeine-induced psychosis.". CNS Spectrums 14 (3): 127–9. PMID 19407709.
  25. ↑ Cerimele, J. M.; A. P. Stern; D. Jutras-Aswad (September 2010). "Psychosis following excessive ingestion of energy drinks in a patient with schizophrenia.". American Journal of Psychiatry 167 (3): 353. doi:10.1176/appi.ajp.2009.09101456. PMID 20194494.
  26. ↑ Broderick, P.; Benjamin, A. B. (2004). "Caffeine and psychiatric symptoms: A review". The Journal of the Oklahoma State Medical Association 97 (12): 538–542. PMID 15732884.
  27. ↑ "White Paper Report on Excited Delirium Syndrome", ACEP Excited Delirium Task Force, American College of Emergency Physicians, 10 September 2009
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