Mental Disorder due

to Stimulant
Iin Mai Syarah
201510401011036

SMF ILMU KESEHATAN JIWA

UNIVERSITAS MUHAMMADYAH MALANG
2016

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
Intoxication
o Caffeine
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

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
Prescription amphetamines induce the release of dopamine in a dosedependent manner; low doses of amphetamines deplete large
storage vesicles, and high doses deplete small storage vesicles.

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.

Negative symptoms commonly observed in schizophrenia are

relatively rare in amphetamine 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.

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.
Post-marketing studies of amphetamines prescribed to children
and adolescents revealed a total of 865 unique case reports
describing signs and/or symptoms of psychosis or mania, with
nearly half reported in children 10 years or younger

History
Amphetamine-related psychiatric disorders can be confused with
psychiatric disorders caused by organic, medical, neurologic,
and/or psychological etiologies.

The causes of amphetamine-related psychiatric disorders usually

can be determined by assessing the patient's history and the
family's genealogy.

The DSM-5 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).

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

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 andtwo (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
Thesigns orsymptoms 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 the patient for medical
complications of amphetamine
abuse, including hyperthermia,
dehydration, renal failure, and
cardiac complications.

During neurologic examination,

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,
buccal oral gyrations, 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.

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.

Histologic Findings
Repeated exposure to amphetamines is theorized to
alter the morphology of dendrites in the prefrontal
cortex

and

in

the

nucleus

accumbens.

Amphetamines may increase the length of dendrites

for longer than 1 month. These alterations may help
explain the behavioral cravings and psychosis that
long-term abuse of amphetamines produces.

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 23 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. AmphetamineRelated Psychiatric Disorders.
http://emedicine.medscape.com/article/289973
-overview
. Diakses pada tanggal 24 April 2016.

THANK YOU