My seminar slides on Management of Substance-Related Psychiatric Disorders - Amphetamines and Methamphetamines

1. Management of
SUBSTANCE-RELATED
Psychiatric Disorders
Wednesday, 19/11/14
A/P Dr. Ramli Musa

2. 1. Ain – AMPHETAMINES
2. Aida – OPIODS & CANNABIS
3. Firdaus – BENZODIAZEPINES & GLUE

3. Harian Metro, 12 February 2014
Kosmo September 2008
Harian Metro, 12 March 2008
Sinar Harian 17 August 2012

4. Utusan Sarawak, 15 May 2009
Harian Metro, 1 April 2009
Harian Metro, 19 March 2011

5. The Star 4 March 2014
BERNAMA August 2014
Sinar Harian, 18 July 2013

6. Laporan Dadah 2013 from Agensi Dadah Kebangsaan

9. 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

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

11. DSM-IV-TR FOR SUBST. DEPENDENCE
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 (or
more) 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 from
the 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 long
distances), 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 problem
that 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)

12. DSM-IV-TR FOR SUBST. ABUSE
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 1 (or
more) 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, or
expulsions 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 a
machine 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 or
exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical
fights)
B. The symptoms have never met the criteria for Substance Dependence for this class of substance.

13. DSM-IV-TR FOR SUBST. INTOXICATION
A. The development of a reversible substance-specific syndrome due to recent ingestion of (or exposure to) a
substance. Note: Different substances may produce similar or identical syndromes.
B. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the
substance 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 mental
disorder.

14. DSM-IV-TR FOR SUBST. WITHDRAWAL
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 other
important areas of functioning.
C. The symptoms are not due to a general medical condition and are not better accounted for by another mental
disorder.

15. 2. Change in DSM-V

16. 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 and
Axes Provided for Further Study”).
CHANGE IN DSM-V
http://pro.psychcentral.com/dsm-5-changes-addiction-substance-related-disorders-alcoholism/004370.html

17. CHANGE IN DSM-V
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.
http://pro.psychcentral.com/dsm-5-changes-addiction-substance-related-disorders-alcoholism/004370.html

18. VIDEO 1 : HISTORY OF AMPHETAMINES

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

20. CLASSIFICATION
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”

21. MEDICAL INDICATIONS
• ADHD (Adderall, Ritalin, Concerta)
• Narcolepsy (Adderall, Ritalin, Vyvanse)
• Treatment-resistant depression (Adderall)
• Obesity (Sibutramine, Phentermine)

22. COMMON USERS
– 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

23. 4. How Amphetamines Work

24. • Acts on CNS
CNS STIMULANT
• Releasing catecholamines (dopamine), from presynaptic stores (reward
pathway) projecting from ventral tegmentum to cortex.
http://www.bnl.gov/bnlweb/pubaf/pr/2001/bnlpr030101.htm

25. VIDEO 2 : REWARD PATHWAY

26. 5. Amphetamine Intoxication & Withdrawal

27. AMPHETAMINE-RELATED PSYCHI 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

28. DSM-IV-TR FOR AMPHETAMINE INTOXICATION
A. Recent use of amphetamine or a related substance (e.g., methylphenidate).
B. Clinically significant maladaptive behavioral or psychological changes (e.g., euphoria or affective
blunting; 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 related
substance:
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.

29. VIDEO 3 : PATIENTS

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

41. WHAT HAPPENS IF YOU STOP TAKING THEM?

42. DSM-IV-TR FOR AMPHETAMINE WITHDRAWAL
A. Cessation of (or reduction in) amphetamine (or a related substance) use that has been
heavy and prolonged.
B. Dysphoric mood and two (or more) of the following physiological changes, developing
within 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 in
social, occupational, or other important areas of functioning.
D. The symptoms are not due to a general medical condition and are not better
accounted for by another mental disorder.

43. 6. Management

44. • Symptomatic
MANAGEMENT
• 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 may
accompany abstinence.

45. 7. Other Specific Amphetamine-Related
Psychiatric Disorders

46. AMPHETAMINE-RELATED PSYCHI 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

47. AMPHETAMINE-RELATED PSYCHI DISORDERS
1. Amphetamine-Induced Anxiety Disorder
Can induce symptoms similar to those seen in obsessive-compulsive
disorder, panic disorder & phobic disorders
2. Amphetamine-Induced Mood Disorder
- Intoxication : manic or mixed mood features
- Withdrawal : depressive mood features
3. Amphetamine-Induced Sexual Dysfunction
High doses and long-term is associated with erectile disorder and other
sexual dysfunctions
4. Amphetamine-Induced Sleep Disorder
- Intoxication : insomnia and sleep deprivation
- Withdrawal : hypersomnolence & nightmares

48. 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)

49. REFERENCES
• 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 Fifth
Edition (2010). Written by Sadock, B.J. & Sadock, V.A. Published by
Lippincott Williams & Wilkins.
• http://www.adk.gov.my/html/pdf/hada2014/01-%20ATS.pdf
• emedicine.medscape.com