Management of Substance-Related Psychiatric Disorders (Amphetamines)

Management of SUBSTANCE-RELATEDPsychiatric Disorders

Wednesday, 19/11/14A/P Dr. Ramli Musa

1. Ain – AMPHETAMINES

3. Firdaus – BENZODIAZEPINES & GLUE

2. Aida – OPIODS & CANNABIS

Harian Metro, 12 February 2014

Kosmo September 2008

Harian Metro, 12 March 2008

Sinar Harian 17 August 2012

Utusan Sarawak, 15 May 2009

Harian Metro, 1 April 2009

Harian Metro, 19 March 2011

The Star 4 March 2014

BERNAMA August 2014

Sinar Harian, 18 July 2013

Laporan Dadah 2013 from Agensi Dadah Kebangsaan

OUTLINES

1. Diagnostic criteria in DSM-IV-TR (Dependence, Abuse, Intoxication, Withdrawal)

2. Change in DSM-V

3. Introduction of Amphetamines (Classification, Indications, Common users)

4. How Amphetamines Work

5. Amphetamine Intoxication & Withdrawal

6. Management

7. Other Specific Amphetamine-Related Psychiatric Disorders

1. Diagnostic criteria in DSM-IV-TR(Dependence, Abuse, Intoxication, Withdrawal)

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (ormore) of the following, occurring at any time in the same 12-month period:

1. tolerance, as defined by either of the following:

a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect

b) markedly diminished effect with continued use of the same amount of the substance

2. withdrawal, as manifested by either of the following

a) the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal fromthe specific substances)

b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms

3. the substance is often taken in larger amounts or over a longer period than was intended

4. there is a persistent desire or unsuccessful efforts to cut down or control substance use

5. a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving longdistances), use the substance (e.g., chain-smoking), or recover from its effects

6. important social, occupational, or recreational activities are given up or reduced because of substance use

7. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problemthat is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)

DSM-IV-TR FOR SUBST. DEPENDENCE

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 (ormore) of the following, occurring within a 12-month period:

1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g.,repeated absences or poor work performance related to substance use; substance-related absences, suspensions, orexpulsions from school; neglect of children or household)

2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating amachine when impaired by substance use)

3. recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)

4. continued substance use despite having persistent or recurrent social or interpersonal problems caused orexacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physicalfights)

B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

DSM-IV-TR FOR SUBST. ABUSE

A. The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) asubstance. Note: Different substances may produce similar or identical syndromes.

B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of thesubstance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment, impaired judgment,

impaired social or occupational functioning) and develop during or shortly after use of the substance.

C. The symptoms are not due to a general medical condition and are not better accounted for by another mentaldisorder.

DSM-IV-TR FOR SUBST. INTOXICATION

A. The development of a substance-specific syndrome due to the cessation of (or reduction in) substance use that

has been heavy and prolonged.

B. The substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or otherimportant areas of functioning.

C. The symptoms are not due to a general medical condition and are not better accounted for by another mentaldisorder.

DSM-IV-TR FOR SUBST. WITHDRAWAL

2. Change in DSM-V

1. Major change with substance abuse and alcohol abuse and dependence disorders : removal of the distinction between“abuse” and “dependence.” The chapter also moves “gambling disorder” into it as a behavioral addiction.

2. Criteria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal,substance/medication-induced disorders, and unspecified substance-induced disorders, where relevant.

3. Two major changes to the new DSM-5 criteria for substance use disorder:

1. “Recurrent legal problems” criterion for substance abuse has been deleted from DSM-5

2. A new criterion has been added: craving or a strong desire or urge to use a substance

4. The threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria. This is a change from DSM-IV,where abuse required a threshold of one or more criteria be met, and three or more for DSM-IV substance dependence.

5. Cannabis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets andAxes Provided for Further Study”).

CHANGE IN DSM-V

http://pro.psychcentral.com/dsm-5-changes-addiction-substance-related-disorders-alcoholism/004370.html

6. Criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5.”

7. Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed:

- 2–3 criteria indicate a mild disorder

- 4–5 criteria, a moderate disorder

- 6 or more, a severe disorder

8. The DSM-5 removes the physiological subtype, as well as the diagnosis for “polysubstance dependence.”

9. Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained re-mission is defined as at least 12 months without criteria (except craving). Additional new DSM-5 specifiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.

CHANGE IN DSM-V

http://pro.psychcentral.com/dsm-5-changes-addiction-substance-related-disorders-alcoholism/004370.html

VIDEO 1 : HISTORY OF AMPHETAMINES

3. Introduction of Amphetamines (Classification, Indications, Common users)

1. MAJOR AMPHETAMINES• Amphetamine

• Dextroamphetamine (Dexedrine)

• Methamphetamine (Desoxyn,“speed”, “yaba/pil kuda”, “syabu”)

• Methylphenidate

• Pemoline (Cylert)

2. RELATED SUBSTANCES• Ephedrine

• Phenylpropanolamine (PPA)

• Khat

• Methcathinone (“crank”)

3. DESIGNER DRUGS• MDMA (“ecstasy”)

• DOM (“STP”)

• MDEA

• MMDA

4. “ICE”• Pure form of methamphetamine

• “Batu kristal”, “kaca”, “diamond”

CLASSIFICATION

• ADHD (Adderall, Ritalin, Concerta)

• Narcolepsy (Adderall, Ritalin, Vyvanse)

• Treatment-resistant depression (Adderall)

• Obesity (Sibutramine, Phentermine)

MEDICAL INDICATIONS

– Students studying for examinations

– Long-distance truck drivers on trips

– Business people with important deadlines

– Athletes in competition

– Soldiers during wartime

In need to increase performance and induce euphoric feelings

COMMON USERS

4. How Amphetamines Work

• Acts on CNS

• Releasing catecholamines (dopamine), from presynaptic stores (rewardpathway) projecting from ventral tegmentum to cortex.

CNS STIMULANT

http://www.bnl.gov/bnlweb/pubaf/pr/2001/bnlpr030101.htm

VIDEO 2 : REWARD PATHWAY

5. Amphetamine Intoxication & Withdrawal

DSM-IV-TR describes:

1. Amphetamine-induced anxiety disorder

2. Amphetamine-induced mood disorder

3. Amphetamine-induced psychotic disorder with delusions

4. Amphetamine-induced psychotic disorder with hallucinations

5. Amphetamine-induced sexual dysfunction

6. Amphetamine-induced sleep disorder

7. Amphetamine intoxication

8. Amphetamine intoxication delirium

9. Amphetamine withdrawal

10.Amphetamine-related disorder not otherwise specified

AMPHETAMINE-RELATED PSYCHI DISORDERS

A. Recent use of amphetamine or a related substance (e.g., methylphenidate).

B. Clinically significant maladaptive behavioral or psychological changes (e.g., euphoria or affectiveblunting; changes in sociability; hypervigilance; interpersonal sensitivity; anxiety, tension, or anger;stereotyped behaviors; impaired judgment; or impaired social or occupational functioning) that developed

during, or shortly after use of amphetamine or a related substance.

C. Two (or more) of the following, developing during, or shortly after, use of amphetamine or a relatedsubstance:

1. tachycardia or bradycardia

2. papillary dilation

3. elevated or lowered blood pressure

4. perspiration or chills

5. nausea or vomiting

6. evidence of weight loss

7. psychomotor agitation or retardation

8. muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias

9. confusion, seizures, dyskinesias, dystonias, or coma

D. The symptoms are not due to a general medical condition and are not better accounted for by

another mental disorder.

DSM-IV-TR FOR AMPHETAMINE INTOXICATION

VIDEO 3 : PATIENTS

GENERAL EXAMINATION

• Anorexia

• Overtalkativeness

• Profuse sweating

• Tics

• Formication

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

FACE

• Acne

• Dilated pupils

• Blurred vision

• Dry mouth and nose

• Excessive grinding of teeth

• Meth mouth

• Dehydration

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

CENTRAL NERVOUS SYSTEM

SIDE EFFECTS OVERDOSE

• Confusion• Fast reflexes• Agitation• Tremor

• Seizure• Psychosis• Compulsive and repetitive

behaviour• Serotonin syndrome• Adrenergic storm

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

CARDIOVASCULAR SYSTEM

SIDE EFFECTS OVERDOSE

• Tachycardia • Hyper/hypotension • Raynaud’s

phenomenon Cardiac arrythmia

• Cardiogenic shock• Cerebral haemorrhage• Circulatory collapse

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

RESPIRATORY SYSTEM

SIDE EFFECTS OVERDOSE

• Tachypnea • Pulmonary edema• Pulmonary hypertension• Respiratory alkalosis

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

URINARY SYSTEM

SIDE EFFECTS OVERDOSE

• Urinary retention• Dysuria

• Oliguria• Kidney failure

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

SYSTEMIC

SIDE EFFECTS OVERDOSE

• Hyperthermia • Hyper/hypokalemia• Hyperpyrexia• Metabolic acidosis

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

ABDOMEN

• Stomach pain

• Loss of appetite

• Nausea

• Weight loss

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

SEXUAL

• Erectile dysfunction

• Frequent erections

• Prolonged erections

1. GENERAL

2. FACE

3. CNS

4. CVS

5. RESPIRATORY

6. URINARY

7. SYSTEMIC

8. ABDOMEN

9. SEXUAL

10. PSYCHOLOGY

SIDE EFFECTS OF STIMULANTS

PSYCHOLOGY

• Increased alertness

• Concentration• Prolonged wakefulness• Insomnia

• Less fatigue

• Elated mood followed by mildly depressed mood

• Sociability

WHAT HAPPENS IF YOU STOP TAKING THEM?

A. Cessation of (or reduction in) amphetamine (or a related substance) use that has beenheavy and prolonged.

B. Dysphoric mood and two (or more) of the following physiological changes, developingwithin a few hours to several days after Criterion A:

1. fatigue

2. vivid, unpleasant dreams

3. insomnia or hypersomnia

4. Increased appetite

5. psychomotor retardation or agitation

C. The symptoms in Criterion B cause clinically significant distress or impairment insocial, occupational, or other important areas of functioning.

D. The symptoms are not due to a general medical condition and are not betteraccounted for by another mental disorder.

DSM-IV-TR FOR AMPHETAMINE WITHDRAWAL

6. Management

• Symptomatic

• Treat specific amphetamine-induced disorders with specific drugs

– Antipsychotics

– Anxiolytics

– Diazepam (Valium)

• Help patient remains abstinent from drug (individual, family and group psychotherapy)

• Deal with underlying depression, personality disorder, or both.

• Bupropion (Wellbutrin) may be of use after patients have withdrawn from amphetamine.It will give feelings of well-being as these patients cope with the dysphoria that mayaccompany abstinence.

MANAGEMENT

7. Other Specific Amphetamine-Related Psychiatric Disorders

DSM-IV-TR describes:

1. Amphetamine-induced anxiety disorder

2. Amphetamine-induced mood disorder

3. Amphetamine-induced psychotic disorder with delusions

4. Amphetamine-induced psychotic disorder with hallucinations

5. Amphetamine-induced sexual dysfunction

6. Amphetamine-induced sleep disorder

7. Amphetamine intoxication

8. Amphetamine intoxication delirium

9. Amphetamine withdrawal

10.Amphetamine-related disorder not otherwise specified

AMPHETAMINE-RELATED PSYCHI DISORDERS

1. Amphetamine-Induced Anxiety DisorderCan induce symptoms similar to those seen in obsessive-compulsivedisorder, panic disorder & phobic disorders

2. Amphetamine-Induced Mood Disorder- Intoxication : manic or mixed mood features

- Withdrawal : depressive mood features

3. Amphetamine-Induced Sexual DysfunctionHigh doses and long-term is associated with erectile disorder and othersexual dysfunctions

4. Amphetamine-Induced Sleep Disorder- Intoxication : insomnia and sleep deprivation

- Withdrawal : hypersomnolence & nightmares

AMPHETAMINE-RELATED PSYCHI DISORDERS

6. Amphetamine-induced psychotic disorder

– Hallmark : presence of paranoia

– Differentiating characteristics from paranoid schizophrenia:

• Hyperactivity

• Generally appropriate affects

• Predominance of visual hallucinations

• Little evidence of disordered thinking

• Confusion and incoherence

• Hypersexuality

– If acute, can be completely indistinguishable from schizophrenia

– Treatment of choice : short-term use of an antipsychotic (eg: haloperidol)

AMPHETAMINE-RELATED PSYCHI DISORDERS

• Oxford Psychiatry Third Edition (2005). Written by Gelder, M.,Mayou, R. & Geddes, J. Published by Oxford University Press.

• Kaplan and Sadock's Synopsis of Psychiatry (10th ed), pp. 407-412

• Kaplan & Sadock’s Pocket Handbook of Clinical Psychiatry FifthEdition (2010). Written by Sadock, B.J. & Sadock, V.A. Published byLippincott Williams & Wilkins.

• http://www.adk.gov.my/html/pdf/hada2014/01-%20ATS.pdf

• emedicine.medscape.com

REFERENCES