Mental disorder due to stimulant

Mental disorder due to stimulantBetty Rachma

stimulantsubstances that induce a number of characteristic symptoms, (alertness with increased vigilance, a sense of well-being, and euphoria)classified by the US Drug Enforcement Agency (DEA)DEA classificationDEA classificationClinical Presentation

Diagnostic Considerations

Delirium (toxic-metabolic, infectious)HyperthyroidismAcute intermittent porphyriaLysergic acid diethylamide (LSD) intoxicationPhencyclidine (PCP) intoxicationCaffeine overuseNeuroleptic malignant syndromeAlcohol, benzodiazepine, or barbiturate withdrawalAnticholinergic overdoseSchizophreniaBipolar disordersAnxiety disorders

WorkupDrug screens for amphetamines. Urine drug screens may be useful for excluding other substances.Routine evaluations (ECG and electrolyte evaluation).

Treatment & ManagementActivated charcoal should be prescribed in a case of acute overdose. Otherwise the treatment should target specific signs and symptoms

Consultation a psychiatrist

Patient and Family Education

Supportive therapyEstablish and maintain ABCs.Decontamination with gastric lavageMonitor vital signs and hydrate with intravenous fluids.Withdrawal related insomnia may be treated with trazodone (75-200 mg), hydroxyzine (25-50 mg), or diphenhydramine (50-100 mg) at bedtime.Benzodiazepines should be avoided unless the patient is also in detox from alcohol/benzodiazepines/opiates.Neuroleptics may be used for the symptomatic treatment of psychosis.Physical restraints may be required in certain cases.an antidepressant is recommended for persistent (> a week) depressive symptoms at a level of moderate or severe or associated with suicidal ideation/attempts.

Amphetamine-Related Psychiatric DisordersDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision(DSM-IV-TR):Amphetamine-inducedanxiety disorderAmphetamine-induced mood disorderAmphetamine-induced psychotic disorder with delusionsAmphetamine-induced psychotic disorder with hallucinationsAmphetamine-inducedsexual dysfunctionAmphetamine-inducedsleep disorderAmphetamine intoxicationAmphetamine intoxicationdeliriumAmphetamine withdrawalAmphetamine-related disorder not otherwise specified

Pathophisiologypsychiatric symptoms inhibition of the dopamine transporter in the striatum and nucleus accumbensamphetamines induce the release of dopamine (dose-dependent manner, low doses of amphetamines deplete large storage vesicles, and high doses deplete small storage vesicles psychotic symptomsAmphetamine-induced psychosis has been used as a model to support the dopamine hypothesis of schizophreniaDelirium caused by amphetamines may be related to the anticholinergic activityepidemiology USA: dependence/abuse rise significantly during this period, from 164,000 in 2002 to 257,000 in 2005Drug Abuse Warning Network (DAWN), 2005:10% of all drug-related hospital emergency department visits were stimulant-related. 26% of all drug-related deaths in Oklahoma City were due to methamphetamine, people aged 20-39 years who are inclined to abuse amphetamine derivatives at rave parties and dance clubs.

Clinical presentationprovides information about the patient's in utero exposure to medications, illicit drugs, alcohol, pathogens, and trauma.occurred when the patient was not exposed to amphetamines?had a psychiatric disorder/symptoms similar in relation to any other drug?When?How often?How much?intoxicated or in withdrawal?attend rave parties?recently increased his or her use or started to binge?

Clinical presentation intoxicationDSM-IV-TRthe patient has recently used an amphetamine or related substanceClinically significant maladaptive behavioral or psychological changes developed Such as:Euphoria or affective bluntingChanges in sociabilityHypervigilanceInterpersonal sensitivityAnxiety, tension, or angerStereotyped behaviorsImpaired judgmentImpaired social or occupational functioning

Two or more of the following conditions :Tachycardia or bradycardiaPupillary dilatationElevated or lowered blood pressurePerspiration or chillsNausea or vomitingEvidence of weight lossPsychomotor agitation or retardationMuscular weakness, respiratory depression, chest pain, or cardiac arrhythmiasDisorientation and memory loss, seizures, dyskinesias, dystonias, or comaThe symptoms are not due to a general medical condition, and another mental disorder does not account for them better than amphetamine intoxication does.

Clinical presentation withdrawalDSM-IV-TR: The patient has recently ceased or reduced heavy or prolonged use of amphetamines or related substances.A dysphoric mood and 2 or more of the following physiologic changes develop ed:FatigueVivid, unpleasant dreamsInsomnia or hypersomniaIncreased appetitePsychomotor retardation or agitationA complete mental status examination (hallucinations, delusions, suicide and/or homicide, orientation, memory, and judgment)The aforementioned symptoms cause clinically significant distress or impairment in terms of social, occupational, or other important areas of functioning.The symptoms are not due to a general medical condition, and another mental disorder does not account for them better than amphetamine withdrawal does.

Clinical presentation physicalDifferential diagnosisCannabis Compound AbuseCocaine-Related Psychiatric DisordersDeliriumDepressionHallucinogensHyperthyroidismHypothyroidismInhalant-Related Psychiatric DisordersInsomniaOpioid AbusePhencyclidine (PCP)-Related Psychiatric DisordersSchizophreniaToxicity, HeroinToxicity, MushroomWernicke-Korsakoff Syndrome

Work upLaboratory test:Finger-stick blood glucose testCBC determinationDetermination of electrolyte levels, including magnesium, amylase, albumin, total protein, uric acid, BUN, alkaline phosphatase, and bilirubin levelsUrinalysisStat urine or serum toxicology screeningBlood test for an alcohol levelif the patient appears intoxicatedHIV and rapid plasma reagin (RPR) testsImaging Studies neurologic impairments (+), CT / MRI: evaluating for subarachnoid and intracranial hemorrhage

Other TestsECG cardiac involvement.EEG seizure disorder.brief psychotic rating scale (BPRS), Beck Depression Scale, violence and suicide assessmentneuropsychological testing assess levels of psychosocial and neurologic function to guide treatmentprojective testing, such as the Rorschach test and the Thematic Apperception Test, can help in clarifying thought disorders.During amphetamine intoxication, MMSEcognitive change.

Treatment medicalmedically stabilizing the patient's condition.Overdose Induced emesis, lavage, or charcoalThe excretion of amphetamines can be accelerated by the use of ammonium chloride, given either IV/PO.Amphetamine intoxication can be treated with ammonium chloride 500 mg every 2-3 hours, IV fluids adequate hydration.psychotic or in danger of harming him or herself or others, a high-potency antipsychotic, aware extrapyramidal symptoms, Agitation benzodiazepines PO, IV, or IM. Lorazepam and chlordiazepoxide are commonly used.Administer naloxone (Narcan) in the event of concurrent opiate toxicityBeta-blockers elevated blood pressure and pulse. also may be helpful with anxiety or panic.

Psychiatric hospitalization may be necessary when psychosis, aggression, and suicidality cannot be controlled.If serotonin syndrome is suspected, stop all SSRI and SNRI medications.

Consultations:NeurologistInternal medicine specialistPsychiatrist substance abuse treatment or further psychiatric stabilization.Social services: Social services coordinate outpatient services

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

Follow upFurther Inpatient Careobservation (mania, severe depression, psychosis, delirium, or if he or she is suicidal or homicidal)delirium placed in a quiet, cool (not cold), dimly lit (not dark) room and, if uncontrollable, placed in restraints.Further Outpatient CareMonitoring closely for recurringPsychiatric follow-up care should occur within, at most, 2 weeks of the initial evaluation ensure compliance.consider a follow-up examination with a neurologist and an internist complications of amphetamine abuse in the specific patient

Inpatient & Outpatient MedicationsIf psychosis persists after the offending substance is eliminated, use of an atypical antipsychotic (risperidone, quetiapine, olanzapine, aripiprazole, ziprasidone) may be considered.Antimanic agents if mania >2 weeks.Antidepressants can be useful if depression persists for 2 weeks after withdrawal.If anxiety >2 weeks, consider the use of nonbenzodiazepine drugs. Medications such as beta-blockers, valproic acid, carbamazepine, or gabapentin have shown promise in patients with substance abuse who also have anxiety.Sleep medication may help patients adjust their circadian rhythm and can be used for approximately 1-2 weeks. (long period, go to sleep clinic)

complicationPsychosisDepressionAnxiety disorderSleep disturbanceMemory impairmentMedical complicationsNeurologic complicationsAbuse of another or several substancesPsychosocial impairmentAffect dysregulation and aggression

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.psychosocial counseling.Hospitalize (suicidal or homicidal)substance abuse counseling.The family must be educated about the patient's addiction and its dangers

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