JURNAL READING

Mental Disorder due to Stimulant

Vonny Riska R
201520401011132

SMF ILMU KEDOKTERAN JIWA

FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH MALANG
2017
Stimulants are substances that induce a number of
characteristic symptoms. CNS effects include alertness
with increased vigilance, a sense of well-being, and
euphoria. Many users experience insomnia and anorexia,
and some may develop psychotic symptoms.
 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
 Substances
• Types of Disorder o Alcohol
– Substance-induced o Amphetamines
• Intoxication o Caffeine
• Withdrawal o Cannabis
• Various psychiatric o Cocaine
symptoms o Hallucinogens
– Substance Use o Inhalants
• Dependence o Nicotine
• Abuse o Opioids
o Phencyclidine
o Sedative-hypnotics
o Polysubstance
 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.
 Pathophysiology

The pathopsysiology of amphetamin-related psychiatric disorders is difficult

to establish, because amphetamines influence multiple neural system.

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 dopamin
reduction.
 Pathophysiology

This increase in dopaminergic activity may becausally 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.
 Physical

During physical examination, assess During neurologic examination,

the patient for medical complications
of amphetamine abuse, including
hyperthermia, dehydration, renal
failure, and cardiac
complications.
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, 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: 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
• 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
 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 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.
 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 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, 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 2-3 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. Amphetamine-Related Psychiatric

Disorders. http://emedicine.medscape.com/article/289973-
overview. Diakses pada tanggal 2 juli 2017.
• Jacob L. Freedman, M.D., and Ken Duckworth, M.D., March
2013. Stimulant Abuse & Mental Illness. www.nami.org