Secondary Schizophrenia (50 page)

be discerned between cocaine users with psychotic
Organic Syndromes of Schizophrenia – Section 3

symptoms and schizophrenia patients with and without cocaine intoxication, the evidence of reliability of
Epidemiology

such diagnostic differences remains lacking. Depend-Yui and colleagues
[2]
suggested that further evidence
ing solely on the clinical presentation is not advis-for stimulant-induced psychosis could be found in the
able given the current state of knowledge. A period
MA abuse epidemic in Japan shortly after World War
of follow-up in the absence of continued drug use is
II, when huge military stores of MA found their way
also usually helpful to confirm the diagnosis
[9].
Of
to the open market in Japan, leading to widespread
course, the primary assumption is that drug-induced
abuse. A significant number of MA abusers devel-syndromes clear with continued abstinence. Although
oped psychosis that did not resolve with discontinu-an idiopathic syndrome may show some improvement
ation of drug use and many patients required years for
with abstinence, it is unlikely to clear altogether. This
recovery. Sato
[15]
reported that 10% of chronic heavy
assumption is examined later. We discuss the issue of
amphetamine users developed a chronic psychotic dis-acute intoxication inasmuch as it may provide clues to
order lasting more than 6 months after cessation of
the nature of the psychopathology to be seen in more
amphetamine use.

protracted cases of drug-induced psychosis.

Nakatani and Hara
[16]
observed that the large-Japanese studies highlighted the difficulties of
scale MA abuse that occurred in Japan provides
researching longer-term effects of stimulants
[10, 11].

an excellent opportunity to further our understand-The widespread use of high-dose injected MA led to
ing of these disorders. Although MA abuse became
hospital admissions of individuals with chronic psy-widespread shortly after World War II, it almost dis-chosis that persisted after substance use had ceased.

appeared during the mid-1950s due to strict legal
The authors noted that many of these individuals
enforcement. However, beginning in the early 1970s,
qualified for a diagnosis of schizophrenia. However,
a new epidemic developed. Nakatani and Hara noted
genetic risks and other possible contributing factors
that some interesting differences regarding patients’

and the presence or absence of predrug use evidence of
profiles have been found between the first and second
increased risk (e.g., presence of prodromal symptoms
epidemics. Many reports during the postwar period
or schizotypal traits) were not assessed. It should be
focused on the clinical resemblance to schizophrenia
noted that large series of chronic cocaine-dependent
and manic-depressive illness. Tatetsu
[17]
concluded
individuals with emergent psychotic disorders could
that typical exogenous symptoms such as clouding of
not be found in the literature.

consciousness, amnesic syndrome, impaired intellec-In a recent study
[12]
, the histories of drug or
tual functioning, and physical signs are generally not
alcohol use in 152 patients diagnosed with either
apparent in patients with MA intoxication. Although
schizophrenia or schizophreniform disorders were
disturbance of consciousness was only sporadically
examined. These researchers reported that 90% of
reported during the first epidemic, studies focused on
the patients with a history of any type of substance
the more recent epidemic have found this symptom
abuse reported the use of cannabis. This study high-to be much more prevalent
[16]
. Nakatani and Hara
lights the inherent difficulty in assessing causality in
speculate that this difference probably reflects a change
a population largely characterized by poly drug use,
in the pattern of usage, with manufactured ampoule
increased life stressors, and possibly other factors like
being commonly used during the postwar era and
head injury. Poly drug use may indeed be a funda-high-density powder from the black market becoming
mentally different problem than use of, or addiction
prevalent during the more recent epidemic.

to, a single substance. Indeed, in another study, psy-One of the most prominent effects of MA abuse
chosis proneness differed between cocaine-dependent
on cognitive function pertains to the development of
and cocaine-and-alcohol-dependent individuals, with
drug-related psychosis
[18].
Aside from the sudden
the comorbid cocaine-and-alcohol-dependent group
psychosis-inducing effects of high doses of MA, an
being significantly more likely to experience a para-enduring form of psychosis can also develop. Studies
noid psychosis with cocaine use
[13].
Although not
from Japan have found that between 36% and 64% of
systematically examined in clinical populations, aniMA users who have experienced psychotic symptoms
mal experimentation suggests that even a short dura-continue to present with these symptoms for more
tion of abuse of PCP-like agents may greatly potentiate
than 10 days after the discontinuation of MA use, even
128

the behavioral effects of psychostimulants
[14].

though MA is eliminated from the blood stream in
Chapter 9 – Stimulants and psychosis

less than 5 days
[19].
Barr and colleagues note that
tion of sensory gating and psychosis vulnerability in
studies in Japan show that MA users with MA psy-cocaine-dependent individuals. Their examination of
chosis are much more likely to experience psychotic
30 abstinent individuals suggested that deficient P50

symptoms again if they use MA and are also more
sensory gating and attention deficits might be associ-likely to have a psychotic relapse when confronted with
ated with increased susceptibility to developing psy-stressful situations, even years after cessation of MA
chotic symptoms in the context of cocaine use.

use
[18].
Another study involving female inmates in
Schuckit’s
[24]
comprehensive review of comor-Japan found that 21% of those with MA psychosis
bidity between substance-use disorders and psychi-remained in a psychotic state for more than 6 months
atric conditions found psychotic symptoms to occur in
[19].
Another 49% returned to their premorbid state
about 40% of amphetamine-dependent patients, espe-but experienced “flashbacks” (i.e. spontaneous recur-cially with higher doses. Schuckit noted that stimulant-rence of psychotic symptoms that would fit criteria
induced psychoses are very likely to clear within sev-for a paranoid-schizophrenia psychotic relapse) dur-eral days to about 1 month of abstinence. Only 1%–
ing their 15–20 months of incarceration. Furthermore,
15% of patients with stimulant-induced psychoses
MA users with persistent or recurrent psychotic symp-maintain some psychotic symptoms after a month.

toms become vulnerable to environmental stress and
Schuckit speculated that this could reflect the fact that
may benefit from antipsychotic medication in a man-approximately 1% of people in any group will develop
ner similar to individuals with schizophrenia.

schizophrenia, or could be the consequence of the pre-The relationship between psychosis and drug
cipitation of longer-term psychotic disorders in pre-dependence was also examined in a large sample of
disposed individuals. However, it is also possible that
prison population in England
[20].
Farrell and col-heavy use of stimulants might cause more long-lasting,
leagues surveyed the clinical condition and history
and hypothetically even permanent, neurochemical
of drug use of 503 individuals. They found that first
changes associated with long-term psychotic disor-use of amphetamines or cocaine, before the age of 16

ders in a small number of individuals, even if not so
years, and severe cannabis or cocaine dependence to
predisposed.

be related to an increased risk of psychosis. These data
agree with our recent finding regarding the signifi-

Clinical picture of amphetamine and

cance of the age of first use as a risk factor for developing acute psychotic symptoms with cocaine use
[21].

cocaine-induced psychotic states

In contrast, severe dependence on heroin was asso-In 1958, Connell
[25]
published his seminal mono-ciated with a reduced risk for developing a psychotic
graph on amphetamine psychosis. He reviewed 36

syndrome
[20].

clinical case reports of patients developing psychosis
Another possible risk factor for psychosis was
following amphetamine use. Of these 36 patients,
described by Cherland and Fitzpatrick
[22]
when they
9 developed a protracted psychotic syndrome per-examined the rate of psychotic and mood-congruent
sisting more than 2 months after withdrawal from
psychotic side effects of stimulant medications in chil-amphetamines, and in 3 subjects, this prolongation of
dren treated for attention-deficit hyperactivity disor-psychotic symptoms was “indefinite.”

der (ADHD). These researchers conducted a chart
In an attempt to compare clinical pictures of
review of all children diagnosed with ADHD in an
amphetamine-induced psychosis and schizophrenia,
outpatient clinic from January 1989 to March 1995.

Bell
[26]
studied 14 patients with amphetamine-During that period, 192 children were diagnosed with
induced psychosis. These patients did not have any
ADHD, 98 (51%) of whom received treatment with
psychotic symptoms prior to abusing drugs. Three
stimulants. These investigators found that six chil-of these patients continued to show psychotic symp-dren developed psychotic or mood-congruent psy-toms for many months after they ceased to take
chotic symptoms during treatment. Cherland and Fitz-amphetamines.

patrick concluded that awareness of the potential for
Ellinwood Jr.
[27]
interviewed 25 subjects
psychotic side effects from stimulant medications is
with chronic amphetamine dependence. Of the 25

important when prescribing for children. Boutros and
users, 8 were classifiable as no-psychosis and 10

colleagues
[23]
also found a link between ADHD

as amphetamine-induced psychosis. Ellinwood Jr.

129

symptoms and psychotic symptoms in their examina-described hyperamnesis as the acute and focused
Organic Syndromes of Schizophrenia – Section 3

memory of the psychotic experience. Not all
erbation after long-term abstinence with minimal use
amphetamine users developed psychosis (although all
(as little as a single dose) of amphetamine or alcohol.

of them were suspicious at some time), and there was
One patient in this cohort relapsed without evidence of
no continuum of severity toward psychosis. Fear and
amphetamine use. Persistent personality changes may
terror were major symptoms mentioned by psychotics.

develop in patients with chronic amphetamine use and
Philosophical concerns increased as patients became
paranoid hallucinatory state. These observations pro-progressively psychotic. Both auditory and visual
vide strong presumptive evidence that certain effects of
hallucinations were noted. Gross distortion of bodily
chronic stimulant abuse can persist long after cessation
image was highly correlated with psychosis. Finally,
of use
[32].
Tomiyama
[33]
found postamphetamine
changes in libido varied greatly but an increase in
chronic psychotic patients to have fewer negative
libido and polymorphous sexual activity most often
symptoms as measured by the Scale for the Assessment
preceded psychosis.

of Negative Symptoms. Tomiyama suggested that these
Clinical descriptions provided by Snyder
[6]
were
patients not be labeled as schizophrenic, and recom-similar to what has been provided in the litera-mended the term “residual psychosis” be used in its
ture except that stereotyped compulsive behavior was
place.

emphasized with patients often pacing back and forth
The findings of Tomiyama
[33]
are in contrast with
with their mouths moving from side to side. The
Srisurapanont and colleagues
[34],
who showed that
stereotyped compulsions seemed to be consistent in
a substantial proportion of such patients do experi-methamphetamine psychosis (MAP)
[27].
The presence negative symptoms. This group
[34]
found pre-ence of tactile hallucinations was also said to differen-morbid schizoid/schizotypal traits to be a serious risk
tiate MAP from schizophrenia where such hallucina-factor for developing a protracted postabstinence psy-tions are rare.