Amphetamine psychosis

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Amphetamine psychosis is a form of psychosis which can result from amphetamine or methamphetamine use. Typically it appears after large doses or chronic use, although in rare cases some people may become psychotic after relatively small doses. Other chemicals or drugs which similarly increase dopamine function (such as cocaine and L-DOPA) can produce similar psychotic states. Because of this, the term stimulant psychosis is sometimes preferred.

Contents 1 Overview 2 Methamphetamine-induced psychotic syndromes 3 Methylphenidate 4 Treatment 5 Emergency Treatment 6 See also 7 References 8 Further reading 9 External links

[edit] Overview

Amphetamine psychosis can include delusions, hallucinations and thought disorder. This is thought to be largely due to the increase in dopamine and perhaps serotonin activity in the mesolimbic pathway of the brain caused by amphetamine-like drugs, although other factors such as chronic sleep deprivation may also play a part. The link between amphetamine and psychosis is one of the major sources of evidence for the dopamine hypothesis of schizophrenia.

The link between amphetamine and psychosis was first made by Young and Scoville in 1938^[1] and was originally considered to be a rare condition. As amphetamine use increased after World War II, largely due to the widespread use of amphetamine compounds in nasal decongestant and dieting preparations, it became clear that chronic amphetamine use often led to psychotic symptoms.

Hallucinations are frequently reported in chronic amphetamine users, with over 80% of users reporting the presence of hallucinatory experiences,^[2] typically as visual or auditory experiences. Delusions, paranoia, fears about persecution, hyperactivity and panic are also reported as the most common features.^[3]

Concurrent to having delusions and hallucinations, chronic amphetamine users may also display stereotyped, repetitive and seemingly purposeless movements, known as 'motor stereotypies' or more commonly as 'knick knacking', or 'tweaking'. Users may describe this condition as being 'spun', 'sketchy', or 'hung-up'. These may include examining, sorting, disassembling, and cleaning. The article on punding gives a more complete description of this behavior. This behavior may appear similar to the symptoms of OCD.

One particular manifestation of psychosis associated with amphetamine use is delusional parasitosis or Ekbom's syndrome, where a person falsely believes themselves to be infested with parasites. However, related behaviour may occur in non-psychotic conditions, where users will realize they are not infested by parasites but will pick at their skin anyway. This more closely resembles obsessive-compulsive disorder.

However, it is important to note that in the above account, the behavior may be similar but the ideation is radically different. There is no ideational connection between compulsive self-grooming and a delusional belief that one is infested with parasites - the "coke horrors" as William S. Burroughs called it.^[4]

In the 1978 novel Requiem for a Dream, which in 2000 was adoped into the film of the same name, character Sara Goldfarb undergoes amphetamine psychosis, due to abusing stimulants and sedatives in an attempt to lose weight, causing her to undergo a complete emotional breakdown, ending up institutionalized in a mental asylum.

[edit] Methamphetamine-induced psychotic syndromes

A 2007 article ^[5] examined the limited amount of documentation and research currently available on methamphetamine-induced psychotic syndromes.

In nearly every case, the symptoms of methamphetamine-induced psychosis will stop within 7-10 days of discontinuing the drug.

After discontinuing the drug, however, a small percentage of long-term or "heavy" users will continue experiencing intermittent psychotic episodes (experiencing hallucination, delusions, and/or paranoia) on an ongoing basis within the first year of abstinence. The 2007 article by Zoric, Rim, Rad, Tsuang et al. looks at these cases a little more closely.

Although not common, these users offer some anecdotal evidence about the neurotoxicity of long-term methamphetamine use, and the healing process that a user experiences when these neurotoxic effects are either partially or fully reversed.

Spontaneous and long-term recurrences (akin to "flashbacks") are hypothesized to be triggered (or exacerbated) by high stress and by sleep deprivation. In extremely rare cases, this condition is documented to persist beyond one year.

The key distinction between this condition and e.g. a psychotic disorder or schizophrenia, is that the symptoms of a methamphetamine-induced psychotic disorder are not considered to be permanent and will eventually subside with abstinence and proper treatment.

[edit] Methylphenidate

Methylphenidate, an amphetamine derivative and potent central nervous system stimulant,^[6][7] can also lead to a psychosis from chronic use. Although the safety profile of short-term methylphenidate therapy in clinical trials has been well established, repeated use of psychostimulants such as methylphenidate is less clear. The long term effects of methylphenidate such as drug addiction, withdrawal reactions and psychosis has received very little research and thus the long term effects of using stimulants for ADHD are largely unknown.^[8] Short term clinical trials show a very low incidence of methylphenidate induced psychosis of 0.01%.^[9] Longer term use of methylphenidate has a psychosis rate of 6% in children.^[10] The long term effects on mental health disorders in later life of chronic use of methylphenidate is unknown.^[11] Concerns have been raised that long-term therapy might cause drug dependence, paranoia, schizophrenia and behavioral sensitisation, similar to other stimulants.^[12] Psychotic symptoms from methylphenidate can include, hearing voices, visual hallucinations, urges to harm oneself, severe anxiety, euphoria, grandiosity, paranoid delusions, confusion, increased aggression and irritability. Methylphenidate psychosis is unpredictable in who it will occur. Family history of mental illness does not predict the incidence of stimulant toxicosis in ADHD children. High rates of childhood stimulant use is found in patients with a diagnosis of schizophrenia and bipolar disorder independent of ADHD. Individuals with a diagnosis of bipolar or schizophrenia who were prescribed stimulants during childhood typically have a significantly earlier onset of the psychotic disorder and suffer a more severe clinical course of psychotic disorder.^[13][14][15]

The withdrawal or rebound symptoms of methylphenidate can include psychosis and depression.^[16] Stimulant withdrawal or rebound reactions can occur and should be minimised in intensity, i.e. via a gradual tapering off of medication.^[17][18][19] A very small study of abrupt withdrawal of stimulants suggests that withdrawal reactions are not typical. Nonetheless withdrawal reactions may still occur in susceptible individuals.^[20]

[edit] Treatment

Typical (haloperidol) and atypical antipsychotics (olanzapine, Risperidone) have been found to be helpful in the initial treatment of amphetamine induced psychosis.^[21] The atypical antipsychotics are more expensive, but have fewer side effects.

When treating persistent methamphetamine-induced psychotic disorders, anti-anxiety drugs (benzodiazepines such as Ativan), may be helpful where anxiety or sleep deprivation are "confirmed" to trigger psychotic symptoms.

Sleeping aids may be also considered for someone who experiences a delayed sleep phase or insomnia after discontinuing the use of amphetamines.

[edit] Emergency Treatment

Severe paranoia and hallucinations should be treated as a medical emergency. A user who is tweaking, has been awake for a long time, and/or believes they are in immediate danger may put themselves (or others) at a grave risk for harm while trying to elude or respond defensively to a delusion or a hallucination (see Fight-or-flight response).

Some facilities may have sufficient funding, programs, and resources to address both mental health and substance abuse issues. This may be the most appropriate clinical setting for an amphetamine user who has presented with psychotic symptoms.

In other situations, facilities only address one or the other. In Chicago, for example, publicly funded substance abuse treatment providers commonly refuse to admit an amphetamine user before any psychiatric emergency (i.e. amphetamine-induced psychosis) is treated by a psychiatric provider.

Additionally, providers may fail to recognize the difference between amphetamine-induced psychosis and another mental illness.

Either situation typically results in a psychiatric commitment (which entails the administration of sedatives and observation over a period of several days) and discharge with little-to-no additional follow-up treatment for substance addiction (when applicable).

[edit] See also

• Amphetamine
• Delusional parasitosis
• Dopamine hypothesis of psychosis
• Psychosis

[edit] References

1. ^ Young, D. & Scoville, W.B. (1938) Paranoid psychosis in narcolepsy and the possible danger of benzedrine treatment. The Medical clinics of North America, 22, 637-46.
2. ^ Kalant, O.J. (1966). One of the more common hallucinations can be referred to a shadow people, seeing and even hearing the dark silhouettes of people that aren't actually there. Also referred to as "meth monsters." The amphetamines: Toxicity and addiction Springfield, Ill: Charles C Thomas Publishers.
3. ^ Ellinwood, E.H, (1967) Amphetamine Psychosis. I. Description of the individuals and processes. Journal of Nervous and Mental Disease, 144, 273-283.
4. ^ "One day you wake up and feel like you've got bugs crawling under your skin. It's the coke horrors. Just relax and shoot in plenty of that good pure G.I. M [translation: government-issue morphine]." William S. Burroughs, Letter From a Master Addict to Dangerous Drugs.
5. ^ Zoric, Rim, Rad, Tsuang et al. (2007) Overview of Methamphetamine-Induced Psychotic Syndromes. UCLA Semel Institute for Neurosciences and Human Behavior
6. ^ Auriel E, Hausdorff JM, Giladi N (October 2008). "Methylphenidate for the Treatment of Parkinson Disease and Other Neurological Disorders". Clin Neuropharmacol. doi:10.1097/WNF.0B013E318170576C. PMID 18978488. 
7. ^ Abramowicz MJ, Van Haecke P, Demedts M, Delcroix M (September 2003). "Primary pulmonary hypertension after amfepramone (diethylpropion) with BMPR2 mutation". Eur. Respir. J. 22 (3): 560–2. PMID 14516151. http://erj.ersjournals.com/cgi/content/full/22/3/560. 
8. ^ Ashton H, Gallagher P, Moore B (September 2006). "The adult psychiatrist's dilemma: psychostimulant use in attention deficit/hyperactivity disorder". J. Psychopharmacol. (Oxford) 20 (5): 602–10. doi:10.1177/0269881106061710. PMID 16478756. http://jop.sagepub.com/cgi/pmidlookup?view=long&pmid=16478756. 
9. ^ "Ritalin & Ritalin-SR Prescribing Information" (PDF). Novartis. April 2007. http://www.pharma.us.novartis.com/product/pi/pdf/ritalin_ritalin-sr.pdf. 
10. ^ Cherland E, Fitzpatrick R (October 1999). "Psychotic side effects of psychostimulants: a 5-year review". Can J Psychiatry 44 (8): 811–3. PMID 10566114. 
11. ^ Kimko HC, Cross JT, Abernethy DR (December 1999). "Pharmacokinetics and clinical effectiveness of methylphenidate". Clin Pharmacokinet 37 (6): 457–70. PMID 10628897. 
12. ^ Dafny N; Yang PB. (15). "The role of age, genotype, sex, and route of acute and chronic administration of methylphenidate: A review of its locomotor effects.". Brain research bulletin. 68 (6): 393-405. PMID 16459193. 
13. ^ Ross RG (July 2006). "Psychotic and manic-like symptoms during stimulant treatment of attention deficit hyperactivity disorder". Am J Psychiatry 163 (7): 1149–52. doi:10.1176/appi.ajp.163.7.1149. PMID 16816217. http://ajp.psychiatryonline.org/cgi/content/full/163/7/1149. 
14. ^ DelBello MP, Soutullo CA, Hendricks W, Niemeier RT, McElroy SL, Strakowski SM (April 2001). "Prior stimulant treatment in adolescents with bipolar disorder: association with age at onset". Bipolar Disord 3 (2): 53–7. PMID 11333062. http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1398-5647&date=2001&volume=3&issue=2&spage=53. 
15. ^ Soutullo CA, DelBello MP, Ochsner JE, et al (August 2002). "Severity of bipolarity in hospitalized manic adolescents with history of stimulant or antidepressant treatment". J Affect Disord 70 (3): 323–7. PMID 12128245. http://linkinghub.elsevier.com/retrieve/pii/S0165032701003366. 
16. ^ Rosenfeld AA (February 1979). "Depression and psychotic regression following prolonged methylphenidate use and withdrawal: case report". Am J Psychiatry 136 (2): 226–8. PMID 760559. http://ajp.psychiatryonline.org/cgi/pmidlookup?view=long&pmid=760559. 
17. ^ Cohen D, Leo J, Stanton T, et al (2002). "A boy who stops taking stimulants for "ADHD": commentaries on a Pediatrics case study". Ethical Hum Sci Serv 4 (3): 189–209. PMID 15278983. 
18. ^ Schwartz RH, Rushton HG (May 2004). "Stuttering priapism associated with withdrawal from sustained-release methylphenidate". J. Pediatr. 144 (5): 675–6. doi:10.1016/j.jpeds.2003.12.039. PMID 15127013. http://linkinghub.elsevier.com/retrieve/pii/S0022347604000228. 
19. ^ Garland EJ (1998). "Pharmacotherapy of adolescent attention deficit hyperactivity disorder: challenges, choices and caveats". J. Psychopharmacol. (Oxford) 12 (4): 385–95. PMID 10065914. 
20. ^ Nolan EE, Gadow KD, Sprafkin J (April 1999). "Stimulant medication withdrawal during long-term therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder". Pediatrics 103 (4 Pt 1): 730–7. PMID 10103294. 
21. ^ Shoptaw SJ, Kao U, Ling WW (2008). "Treatment for amphetamine psychosis". Cochrane Database Syst Rev (4): CD003026. doi:10.1002/14651858.CD003026.pub2. PMID 18843639. 

[edit] Further reading

• Connell, P.H. (1961) Amphetamine Psychosis. Oxford University Press.

[edit] External links

• Chronic amphetamine use and abuse - Review published in 2000.