Substance Related Disorders Reza Bidaki md . pSYCHIATRIST

1. Substance Related DisordersReza Bidakimd. pSYCHIATRIST

3. Stimulants Cocaine Ephedrine Methamphetamine Methylphenidate

4. Amphetamine-related psychiatric disorders • resulting from intoxication or long-term use of amphetamines or amphetamine derivatives • Such disorders can also be experienced during the withdrawal period from amphetamines • often self-limiting after cessation, though, in some patients, psychiatric symptoms may last several weeks after discontinuation.

5. SHORT-TERM EFFECTS • exhaustion, apathy and depression—the “down” that follows the “up.” It is this immediate and lasting exhaustion that quickly leads the stimulant user to want the drug again. Soon he is not trying to get “high,” he is only trying to get “well”—to feel any energy at all

6. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) describes the following 10 amphetamine-related psychiatric disorders • Amphetamine-induced anxiety disorder • Amphetamine-induced mood disorder • Amphetamine-induced psychotic disorder with delusions • Amphetamine-induced psychotic disorder with hallucinations • Amphetamine-induced sexual dysfunction • Amphetamine-induced sleep disorder • Amphetamine intoxication • Amphetamine intoxication delirium • Amphetamine withdrawal • Amphetamine-related disorder not otherwise specified

7. Use of amphetamine and methamphetamine is widespread in the general population • and common among patients with psychiatric disorders

8. Some individuals experience paranoia during withdrawal as well as during sustained use • Amphetamine use may elicit or be associated with the recurrence of other psychiatric disorders • People addicted to amphetamines sometimes decrease their use after experiencing paranoia and auditory and visual hallucinations • amphetamines can be psychologically but not physically addictive

9. The symptoms of amphetamine-induced psychiatric disorders can be differentiated from those of related primary psychiatric disorders by time • If symptoms do not resolve within one month after the amphetamines are discontinued, a primary psychiatric disorder should be suspected

10. Differentiation with schizophrenia • Amphetamine-induced psychosis (delusions and hallucinations) can be differentiated from psychotic disorders when symptoms resolve after amphetamines are discontinued • Absence of first-rank Schneiderian symptoms, anhedonia, avolition, amotivation, flat affect, further suggests amphetamine psychosis • Symptoms of amphetamine use may be indistinguishable from cocaine use. Amphetamines, unlike cocaine, do not cause local anesthesia and have a longer psychoactive duration

11. faster recovery and resolve more • completely compared to schizophrenic psychosis • Increased vulnerability for • acute amphetamine induced psychosis seen among schizophrenia, schizotypal personality and, to a certain degree other psychiatric disorders, non-psychiatric individuals who previously have experienced

12. Amphetamines may induce symptoms of psychosis very similar to those of acute schizophrenia spectrum psychosis

13. Amphetamine-induced delirium follows a reversible course similar to other causes of delirium, by its relationship to amphetamine intoxication • After the delirium subsides, little to no impairment is observed • Delirium is not a condition observed during amphetamine withdrawal

14. Mood disorders similar to hypomania and mania can be during intoxication with amphetamines • Depression can occur during withdrawal, and repeated use of amphetamines can produce antidepressant-resistant amphetamine-induced depression • Low-dose amphetamines can be used as an adjunct in the treatment of depression, especially in patients with medical compromise, lethargy, hypersomnia, low energy, or decreased attention.

15. Sleep disorder • Sleep disturbances appear in a fashion similar to mood disorders • During intoxication, sleep can be decreased markedly • In withdrawal, sleep often increases • A disrupted circadian rhythm can result from late or high doses of prescription amphetamines or from chronic or intermittent abuse of amphetamines

16. Sleep disorder • Individuals who use prescription amphetamines can easily correct their sleep disturbance by lowering the dose or taking their medication earlier in the day than they have been • Insomnia is the most common adverse effect of prescription amphetamines

17. Amphetamine-Induced Sleep Disorder • psychostimulants inhibit sleep • drug use patterns frequently associated with amphetamine-type stimulants (i.e., binges or “runs”) lead to disruptions of normal sleep–wake cycles, because drug users forgo sleep for the sake of drug use • After drug cessation, particularly after continued, heavy use, amphetamine users develop hypersomnolence that can persist for weeks (i.e., “crashes”) • Because amphetamines have the potential to damage brain monoaminergic neurons, which are known to play an important role in sleep modulation (see the section “Amphetamine-Induced Neurotoxicity”

18. Sleep Paralysis • common medical condition • as a Sleeping Disordercomplete to partial paralysis of arms, legs and upper torso, a tight or heavy pressure on your chest sometimes with a choking sensation and almost always experienced to fall into sleep or just come out of sleepThe most remarkable symptoms of SP are the accompanying audio and/or visual hallucinations often causing extreme terror and panic in it's sufferers, who more often than not mistakenly believe they are being visited by aliens, malevolent beings and other evil presences 

20. Prominent anxiety symptoms • Generalized anxiety, panic attacks, obsessive-compulsive symptoms, or phobia symptom • during intoxication on a substance or during withdrawal

21. substance-induced anxiety disorder as listed in the DSM-IV-TR  • Prominent anxiety, panic attacks, or obsessions or compulsions. • Symptoms develop during, or within one month, of intoxication or withdrawal from a substance or medication known to cause anxiety symptoms. • Symptoms are not actually part of another anxiety disorder (such as generalized anxiety disorder, phobias, panic disorder, or obsessive-compulsive personality disorder that is not substance induced • if the anxiety symptoms began prior to substance or medication use, then another anxiety disorder is likely. • Symptoms do not occur only during delirium • Symptoms cause significant distress

22. Prognosis Anxiety symptoms induced by substance intoxication usually subside once the substance responsible is eliminated Symptoms persist depending on the half-life of the substances (i.e., how long it takes the before the substance is no longer present in an individual's system) Symptoms, therefore, can persist for hours, days, or weeks after a substance is last used Obsessive-compulsive symptoms induced by substances sometimes do not disappear, even although the substance inducing them has been eliminated More intensive treatment for the obsessive-compulsive symptoms would be necessary and should include a combination of medication and behavioral therapy

23. Stimulant Abuse and Sexual Addiction • cross-addictions • switch from one addiction to another • co-occurring addictions struggle with multiple addictions simultaneously • Cross and co-occurring disorders are especially common with sex addicts • The most common secondary drugs of choice for sex addicts are amphetamines

24. Crystal methamphetamine is the number one option • called “the sex drug,” • meth is the preferred “party favor” for anonymous Internet and smartphone hookups • most commonly abused drug among prostitutes (of both genders) • Sex addicts also use cocaine, crack cocaine, and almost any other stimulant

25. Cocaine-Induced Psychotic Disorder cocaine-related paranoia is common with heavy use the diagnosis of cocaine-induced psychotic disorder is reserved for cases in which there is no insight as to the drug-related nature of the symptoms, or when symptoms exceed the quality or severity characteristic of cocaine intoxication

26. Learning and Memory abnormalities in brain areas involved in essential pathways of learning and memory. The dysfunction in these areas that is seen with cocaine dependence Conventional re-inforcers produce a dopamine response the response to cocaine does not diminish in this way, and some laboratory animals will self-administer cocaine in preference to food and water and to the point of death. • Cocaine dependence and related behaviors can be understood as forms of behavioral conditioning

27. Cocaine-induced mood or anxiety disorders are distinguished from mood and anxiety symptoms expected during the typical course of intoxication or withdrawal by their intensity, onset, and time course • neurovegetative symptoms suggesting a major depressive episode may be present, full criteria for major depressive disorder or hypomania need not be met • Similarly, the diagnostic criteria for cocaine-induced anxiety disorder require only the presence of prominent anxiety, obsessions, compulsions, or panic attacks in the setting of recent cocaine use

28. cocaine-induced disorders • cocaine-induced sexual dysfunction, sleep disorder, and cocaine-related disorder • Stimulants such as cocaine are at times used for their purported enhancement of sexual function

29. Sleep • Cocaine may also produce a sleep disorder, typically characterized by periods of insomnia during intoxication and hypersomnia during withdrawal • Insomnia during cocaine withdrawal is also commonly described • Sleep cycles may be shifted when binges extend into the night or when withdrawal-induced hypersomnia leads to daytime sleeping

30. Ecstasy may refer to • Ecstasy (emotion), a trance or trance-like state in which a person transcends normal consciousness • Religious ecstasy, a state of consciousness characterized by expanded spiritual awareness, visions or absolute euphoria • Ecstasy (philosophy) , a term used to mean "outside itself" • Ecstasy (drug) , a colloquial term for the drug MDMA

31. 1970 • chemist Alexander Shulgin • introduced ecstasy to those with an interest in drug-assisted psychotherapy • The psychotherapists considered the drug to be moderate in its effects, which were principally characterised by feelings of empathic understanding for others and a release of emotions • potential for overcoming 'blocks' in psychotherapy and enhancing insights

32. a popular drug • positive effects that a person experiences within an hour or so after taking a single dose • feelings of mental stimulation, emotional warmth, empathy toward others, a general sense of well being, and decreased anxiety. enhanced sensory perception as a hallmark of the MDMA experience.

33. 3,4methylenedioxymethamphetamine (MDMA)MDMA • euphoria, high energy, and social disinhibition lasting 3-6 hours • The drug is often consumed in dance clubs, where users dance vigorously for long periods • toxicity and dehydration • severe hyperthermia

34. ecstasy users • Substance-induced affective, anxiety and cognitive disorders occurred more frequently among ecstasy users than polydrug controls. The life-time prevalence of ecstasy dependence amounted to 73% in the ecstasy user groups. More than half of the former ecstasy users and nearly half of the current ecstasy users met the criteria of substance-induced cognitive disorders at the time of testing

35. associated with a number of psychiatric symptoms that have persisted after cessation of the drug

36. Rare Conditions • As with amphetamine • confusion, anxiety, panic attacks, depression, sleeping difficulties, depersonalization, derealization, hallucinations, flashbacks, paranoia, psychosis, tolerance and dependency syndromes, and subsequent addiction to sedatives

37. Ritaline • Methylphenidate is a central nervous system stimulant drug that has become the primary drug of choice in treating attention-deficit/hyperactivity disorder in children • Abuse often entails the use of large doses, which may be taken intranasally or intravenously

38. BRAND NAMES • Ritalin ConcertaBiphetamine Dexedrine • STREET NAMES • R-ball • Skippy • The smart drug • Vitamin R • JIF • Kibbles and bits Speed • Truck drivers • Bennies Black beauties • Crosses

39. Ritaline • Intranasal abuse produces effects rapidly that are similar to the effects of cocaine in both onset and type

40. Hallucinations • Paranoia • Euphoria • manic-like states • delusional disorder • Out of contol • Suicide Ideation • Intravenous abuse of methylphenidate associated with psychosis

41. Bruxism • repeated touching • stereotypic • confusion • disoriented behavior • obsessive-compulsive tendencies, aggressiveness • repetitive behaviors

42. To summarize • the psychiatric side effects of stimulants are quite similar giving more support to the idea that almost all CNS stimulants will produce a similar clinical picture • All participants in therapy need to be educated about the abuse potential of stimulants