Methamphetamine Psychosis

Methamphetamine Psychosis (MAP)

According to Chen et al (2005), it remains unclear why some methamphetamine (meth) users develop psychotic symptoms, while others use meth regularly over long periods and remain unscathed. Their research found that the greater the familial loading for schizophrenia, the more likely a meth user is to develop psychosis, and the longer that psychosis is likely to last.

The main characteristic of MAP is the presence of prominent hallucinations and delusions (APA, 2000). The duration of MAP is variable. In most cases the severe symptoms will abate over a period of hours as the meth and its amphetamine metabolites are cleared from the body. However, some MAP may persist for days or years and a small percentage of users may never recover. It is important to note that MAP can reemerge as a result of stress alone. In fact, a patient with a history of MAP may exhibit symptoms while abstaining from all exogenous psychoactive substances.

MAP closely resembles paranoid schizophrenia. Differentiating MAP from schizophrenia can be difficult in the acute setting. Clients who are psychotic will be unable to provide a reliable history, this information may need to be obtained from a significant other. A diagnosis of MAP should be considered after a physical exam, urine drug screen and the absence of evidence indicating a preexisting or independent mental disorder. The patient should be assessed for the following manifestations of psychosis:

Hallucinations: False perceptions associated with any of the five senses.

Auditory - A false perception of sound. This is the most frequent type of hallucination. Most frequently the user hears voices. Command hallucinations are “Voices” that may issue commands for violence to others. For example: the user hears voices telling him to kill. This may place the user or the health care professional in a potentially dangerous situation.
Visual - Seeing a person, object or animal that does not exist in the environment. For example: a user sees a lion coming toward him.
Olfactory - A false perception of smelling odors that are not present in the environment. For example: the user smells his brain rotting.
Tactile - A false perception of the sense of touch often of something on or under the skin. Formication (US Dept. Of Justice, 1996) is an advanced form of hallucination often associated with methamphetamine use during which the user feels sensations on or beneath the skin. The user often scratches at the “bugs” trying to remove them, but instead the abuser gouges the skin, leaving scars. The scars indicate that the abuser has experienced formication or “crank bugs".
Gustatory - A false perception of the sense of taste. For example: the user refuses to eat because he tastes poison in his food.

Instant Feedback:
Formication is a tactile hallucination.

Delusions: False personal beliefs that are inconsistent with the person's intelligence or cultural background. Delusions cannot be corrected by reasoning. Some common delusions include:

Delusions of Persecution - The person feels threatened and believes that others intend to harm him in some way. For example: the individual thinks that the CIA intends to kill him.
Delusions of Grandeur - The individual has an exaggerated feeling of importance, power or knowledge. Example: The person thinks that he is in control of the state.
Delusions of Reference - The person thinks that unrelated events or happenings are somehow connected to them usually in a negative way. Example: the user watching TV thinks the news broadcaster is trying to get a message to him.
Delusions of being controlled - the person believes certain objects or persons have control over his/her behavior. For example: the individual believes that the president of the United States has control over his behavior.
Somatic Delusions - The individual believes that his/her body or parts of the body are changing or being distorted. For example: the person believes his brain is rotting.

Paranoia: The person has extreme suspicion of others, their actions or perceived intentions. For example: a person saw a live duck on the river and thought the police had placed a camera in the duck to watch him.

Obsessions: According to MacKenzie and Heischober (1997), compulsion and repetitive behaviors are manifestations of chronic use. Users may be obsessed with particular thoughts or repetitively perform rituals involving cleaning, assembling and disassembling objects, repetitive verification or hoarding. Mac Kenzie and Heischober (1997) recommend that patients, who have histories of any compulsive behaviors, including compulsive sexual behaviors, should be evaluated carefully.

Medical Management of Methamphetamine Psychosis:

The MAP patient presents a potential risk of injury to him/herself and to the healthcare staff. MAP patients may be agitated, aggressive and highly suspicious. When this is the case, the safety of the patient and those in the vicinity is primary.

A sense of safety and reassurance is necessary to the development of every therapeutic relationship. Early involvement by a skilled psychiatric clinician may defuse tension and facilitate pharmacologic treatment. The available literature reveals a common MAP ER treatment protocol that includes the use of a benzodiazepine to control agitation and an antipsychotic to control symptoms of psychosis.

In 2006 the American College of Emergency Physicians issued the following recommendations for the effective pharmacologic treatment of the acutely agitated patient in the ED:

"1. Use a benzodiazepine (lorazepam or midazolam) or a
conventional antipsychotic (droperidol* or haloperidol)
as effective monotherapy for the initial drug treatment
of the acutely agitated undifferentiated patient in the
ED.

2. If rapid sedation is required, consider droperidol*
instead of haloperidol.

3. Use an antipsychotic (typical or atypical) as effective
monotherapy for both management of agitation and
initial drug therapy for the patient with known
psychiatric illness for which antipsychotics are indicated.

4. Use a combination of an oral benzodiazepine
(lorazepam) and an oral antipsychotic (risperidone) for
agitated but cooperative patients.

5. The combination of a parenteral benzodiazepine
and haloperidol may produce more rapid sedation than
monotherapy in the acutely agitated psychiatric patient
in the ED."

Droperidol currently carries a FDA warning about cases of sudden death at high doses (greater than 25 mg) in patients at risk for cardiac arrhythmias. There are a number of unpleasant and dangerous side effects common to butyrophenone antipsychotics like haloperidol, droperidol. These drugs act by blocking receptors in the CNS. Common side effects include antidopaminergic manifestations like: orthostatic hypotension, photosensitivity, decreased libido, gynecomastia, weight gain, extra-pyramidal symptoms (pseudoparkinsonism, akinesia, akathisia, dystonia, oculogyric crisis) tardive dyskinesia, and neuroleptic malignant syndrome. Anticholinergic side effects include: dry mouth, blurred vision, urinary retention and constipation. It is very important that the nurse be well informed on the action and side effects. Additional information is available on the web http://www.rxlist.com

Instant Feedback:
Haldol is an effective treatment for methamphetamine psychosis.