|Classification and external resources|
|ICD-10||F14.5 & F15.5|
Stimulant psychosis is a psychotic disorder that occurs in some people who use stimulant drugs. Stimulant psychosis commonly occurs in people who abuse stimulants, but it also occurs in some patients taking therapeutic doses of stimulant drugs under medical supervision.
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, thought disorder, and, in extreme cases, catatonia.
In cases of stimulant psychosis (but not organic psychosis) patients tend to also present with the physical symptoms of prolonged stimulant abuse or acute overdose. These additional symptoms may include aggression, arrhythmia, dilated pupils, diarrhea, hypertension, hyperthermia, nausea, rapid breathing, restlessness, seizures, sleep deprivation, tremor, and vomiting.
Stimulants known to cause psychosis
Drugs in the class of amphetamines, or substituted amphetamines, are known to induce "amphetamine psychosis" typically when chronically abused or used in high doses. In an Australian study of 309 active methamphetamine users, 18% had experienced a clinical level psychosis in the past year. 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. 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. However it has been suggested that around 5–15% of users fail to make a complete recovery in the long term. Furthermore, even at a small dose, the psychosis can be quickly reestablished. Psychosocial stress has been found to be an independent risk factor for psychosis relapse even without further substituted amphetamine use in certain cases.
The symptoms of acute amphetamine psychosis are very similar to those of the acute phase of schizophrenia although in amphetamine psychosis visual hallucinations are more common and thought disorder is rare. Amphetamine psychosis may be purely related to high drug usage, or high drug usage may trigger an underlying vulnerability to schizophrenia. 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. The disorders are often distinguished by a rapid resolution of symptoms in amphetamine psychosis, while schizophrenia is more likely to follow a chronic course.
Although rare and not formally recognized, 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.
Cocaine has a similar potential to induce temporary psychosis with more than half of cocaine abusers reporting at least some psychotic symptoms at some point. 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. Delusional parasitosis with formication ("cocaine bugs") is also a fairly common symptom.
Methylphenidate, better known by its trade name Ritalin, is a central nervous system stimulant with a similar mechanism of action to cocaine. Chronic abuse of methylphenidate can also lead to psychosis. Although 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, the specific effects of long-term use of methylphenidate, even at therapeutic doses, remain largely unknown. A naturalistic study published in 1999 with an average follow up time of 21 months showed that 6 of 98 children and adolescents who were prescribed methylphenidate in an outpatient clinic developed psychotic symptoms while taking the drug at therapeutic dosages (the exception being a 17 year old on 80 mg daily) with most improving after drug cessation. However the lack of a control group makes it impossible to attribute these effects to the medication.
Concerns have been raised that long-term therapy might cause drug dependence, paranoia, schizophrenia, and behavioral sensitization in a similar manner to other stimulant drugs. 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. It is difficult to predict who will develop methylphenidate psychosis as family history of mental illness does not predict the incidence of stimulant toxicosis in children with ADHD.
Withdrawal symptoms of methylphenidate can include psychosis and depression and can be minimized by gradually tapering off the medication. A very small study (19 subjects) of abrupt withdrawal from stimulants used at therapeutic doses for ADHD and chronic tic disorder suggests that withdrawal reactions are not typical. Nonetheless withdrawal reactions may still occur in susceptible individuals.
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.
Caffeine-induced psychosis is infrequently reported in medical literature and remains controversial due to a lack of study or evidence. It is not clear whether it occurs by a similar mechanism to other stimulant psychoses or whether it is an entirely different process. Like other stimulants caffeine increases dopamine levels though only indirectly. A co-factor of caffeine-induced psychosis may be malnutrition especially in a diet lacking in the B-vitamins. High chronic doses of caffeine, theobromine or theophylline can lead to an exhaustion of the nervous system which may form the basis for a subsequent psychosis.
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. 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. Despite some superficial similarities in presentation excited delirium is a distinct (and more serious) condition than stimulant psychosis.
- Delusional parasitosis
- Dopamine hypothesis of psychosis
- Excited delirium
- Substance-induced psychosis
- Curran, Catherine et al., Stimulant psychosis: systematic review, The British Journal of Psychiatry (2004) 185: 196–204
- Amphetamine – http://www.drugs.com/amphetamine.html
- Shoptaw SJ, Kao U, Ling W. Treatment for amphetamine psychosis (Review). Cochrane Database of Systematic Reviews 2009 Issue 1.
- McKetin R, McLaren J, Lubman DI, Hides L. The prevalence of psychotic symptoms among methamphetamine users. Addiction 2006;101(10):1473–8.
- Dore G, Sweeting M. Drug-induced psychosis associated with crystalline methamphetamine. Australasian Psychiatry 2006;14(1):86–9.
- Srisurapanont M, Ali R, Marsden J, Sunga A, Wada K,Monteiro M. Psychotic symptoms in methamphetamine psychotic in-patients. International Journal of Neuropsychopharmacology 2003;6(4):347–52.
- Sato M, Numachi Y, Hamamura T. Relapse of paranoid psychotic state in methamphetamine model of schizophrenia. Schizophrenia Bulletin 1992;18(1):115–22.
- Hofmann FG (1983). A Handbook on Drug and Alcohol Abuse: The Biomedical Aspects (2nd ed.). New York: Oxford University Press. p. 329.
- Yui K, Ikemoto S, Goto K. Factors for susceptibility to episode recurrence in spontaneous recurrence of methamphetamine psychosis. Annals of the New York Academy of Sciences 2002;965:292–304.
- 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.
- Chen CK, Lin SK, Pak CS, Ball D, Loh EW, Murray RM. Morbid risk for psychiatric disorder among the relatives of methamphetamine users with and without psychosis. American Journal of Medical Genetics. Part B, Neuropsychiatric Genetics 2005;136(1):87–91.
- 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.
- J Child Adolesc Psychopharmacol. 2002 Spring;12(1):63-7.Can stimulant rebound mimic pediatric bipolar disorder? Sarampote CS, Efron LA, Robb AS, Pearl PL, Stein MA
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, DSM-IV-TR. Washington, DC: American Psychiatric Association; 2000.
- Prog Neuropsychopharmacol Biol Psychiatry. 2006 Aug 30;30(6):1097-102. Epub 2006 Jun Are psychostimulants a treatment option in mania? Hegerl U, Sander C, Olbrich S, Schoenknecht P.
- Brady KT, Lydiard RB, Malcolm R, Ballenger JC. Cocaine-induced psychosis. J Clin Psychiatry. 1991;52:509–512.
- Thirthalli J., Vivek B. (2006). "Psychosis Among Substance Users". Curr Opin Psychiatry 19 (3): 239–245. doi:10.1097/01.yco.0000218593.08313.fd.
- Elliott, A., Mahmood, T. and Smalligan, R. D. (2012), Cocaine Bugs: A Case Report of Cocaine-Induced Delusions of Parasitosis. The American Journal on Addictions, 21: 180–181.
- http://psy.psychiatryonline.org/cgi/reprint/22/10/845 Drug-induced psychosis: Emergency diagnosis and management, Psychosomatics. DiSCLAFANI et al. 22 (10): 845. 1981 Accessed 5-20-2010
- Auriel E, Hausdorff JM, Giladi N (October 2008). "Methylphenidate for the Treatment of Parkinson Disease and Other Neurological Disorders". Clin Neuropharmacol 32 (2): 75–81. doi:10.1097/WNF.0B013E318170576C. PMID 18978488.
- 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. doi:10.1183/09031936.03.00095303. PMID 14516151.
- Morton WA, Stockton GG. Methylphenidate abuse and psychiatric side effects. Prim Care Companion J Clin Psychiatry 2000;2:159–64.
- Spensley J, Rockwell D (April 1972). "Psychosis during Methylphenidate Abuse". New England Journal of Medicine 286: 880–1. doi:10.1056/NEJM197204202861607.
- "Ritalin & Ritalin-SR Prescribing Information" (PDF). Novartis. April 2007.
- 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.
- Kimko HC, Cross JT, Abernethy DR (December 1999). "Pharmacokinetics and clinical effectiveness of methylphenidate". Clin Pharmacokinet 37 (6): 457–70. doi:10.2165/00003088-199937060-00002. PMID 10628897.
- Cherland E, Fitzpatrick R (October 1999). "Psychotic side effects of psychostimulants: a 5-year review". Can J Psychiatry 44 (8): 811–3. PMID 10566114.
- Dafny N; Yang PB. (15 February 2006). "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. doi:10.1016/j.brainresbull.2005.10.005. PMID 16459193.
- 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.
- 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.
- 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.
- Garland EJ (1998). "Pharmacotherapy of adolescent attention deficit hyperactivity disorder: challenges, choices and caveats". J. Psychopharmacol. (Oxford) 12 (4): 385–95. doi:10.1177/026988119801200410. PMID 10065914.
- 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. doi:10.1542/peds.103.4.730. PMID 10103294.
- Hedges, D. W.; F. L. Woon; S. P. Hoopes (September 2009). "Caffeine-induced psychosis.". CNS Spectrums 14 (3): 127–9. PMID 19407709.
- 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.
- 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.
- Solinas, Marcello; Sergi Ferre,Zhi-Bing You, Marzena Karcz-Kubicha,Patrizia Popoli, and Steven R. Goldberg (August 2002). "Caffeine Induces Dopamine and Glutamate Release in the Shell of the Nucleus Accumbens" (PDF). The Journal of Neuroscience 14 (3): 127–9. Retrieved 16 May 2010.
- http://health.howstuffworks.com/caffeine4.htm How Caffeine Works
- "White Paper Report on Excited Delirium Syndrome", ACEP Excited Delirium Task Force, American College of Emergency Physicians, 10 September 2009