The Relationship Between Stimulants and Psychosis

The stimulant class of drugs includes both illicit and legal drugs. However, all are central nervous system (CNS) stimulants, which means that they increase brain activity. Stimulant abuse carries an inherent risk for psychosis, a state that may include agitation, hallucinations, paranoia, and delusions.² This article highlights the properties of stimulants, their symptoms and risks, and the treatments available for those struggling with addiction.

Stimulant Overview

Commonly abused stimulants include methamphetamine, cocaine, methylphenidate, and amphetamines.^3,5 Physicians prescribe stimulants, such as Adderall, Concerta, and Ritalin, for attention-deficit hyperactivity disorder (ADHD), narcolepsy, and more rarely for depression that hasn’t responded to conventional interventions.⁴ These medications help boost focus, calmness, and overall learning and thinking abilities for people with ADHD.⁵ However, people without ADHD often abuse prescription stimulants for their desired effects of wakefulness, attention, and euphoria.

A popular stimulant of abuse is cocaine, which is largely illicitly produced from the South American coca plant and induces intense feelings of pleasure, and increased energy, confidence, and sex drive.³ Similarly, methamphetamine, which appears in both pill or powder form, also produces similar effects, but with a significantly longer half-life (meaning a longer, sustained high).³ Though prescription methamphetamine (e.g., Desoxyn) exists for a limited number of medical indications, crystal methamphetamine, or crystal meth, predominates the illicit market, and often resembles rocks or pieces of glass.³

Due to their desirable effects and unpleasant withdrawal symptoms when use is reduced or stopped, stimulants can quickly lead to compulsive use or addiction. Currently, the DEA classifies many stimulants as Schedule II controlled substances, meaning that, while they might have acceptable medical use, they also present with a high potential for abuse.⁶

Statistics

Stimulant abuse is extremely prevalent due to their desired effects, such as feelings of well-being, increased focus and concentration, suppressed appetite, and overall wakefulness. Some statistical examples of the alarmingly prevalent issue of stimulant abuse are as follows:^1,3,7

• 1.5 million people reported using cocaine in 2014.
• 569,000 Americans reported past-month use in a 2014 survey.
• Each year, approximately 137,000 college students initiate non-medical use of prescription stimulants (400 students each day).
• Approximately 1.7 million people misused prescription stimulants in 2016.
• In 2016, approximately 540,000 people aged 12 or older met criteria for a stimulant use disorder.¹

Symptoms of Psychosis

Research suggests a strong relationship between amphetamine misuse and the development of acute psychosis. While exact statistics on prevalence vary, between 8-46% of people abusing amphetamines report drug-induced psychosis.⁸

A study of people with pre-existing psychosis or psychotic features, regardless of their mental state at time of experimentation, revealed that large enough doses of stimulants can result in a brief exacerbation of psychosis ratings.⁹ Chronic, high-dose “binging” can especially exacerbate psychotic symptoms.

Signs and symptoms of substance-induced psychosis can include:^2,8,10

• Paranoid delusions.
• Suspicion.
• Grandiosity.
• Auditory or visual hallucinations.
• Severe agitation.
• Impaired concentration.
• Repetitive behaviors.
• Increased motor activity.
• Disorganized thoughts.
• Elevated anxiety.

Stimulant-induced psychosis can be extremely dangerous and detrimental to both the user and the people around the user. Because someone in a psychotic state often acts illogically and irrationally, an elevated risk of violence, self-harm, and suicide exists. When people develop full-blown psychosis due to stimulant abuse, they may need to be hospitalized in the emergency room or in a psychiatric hospital for monitoring and stabilization.

Treatment and Care

Some people in psychosis will need emergent psychiatric hospitalization to receive necessary medical stabilization.² This is especially true if the user becomes violent or presents as a danger to themselves or others. While antipsychotic medications, such as olanzapine and haloperidol, can provide immediate relief for psychotic symptoms, no evidence exists to demonstrate whether they can prevent a relapse of psychotic symptoms.²

In acute psychosis, the user’s vital signs will be closely observed, as stimulants can rapidly increase heart rate, blood pressure, and body temperature.⁸ Furthermore, because stimulant overdose can occur, the user may present at risk for cardiac arrhythmia, seizures, and stroke.¹⁰ Due to the potentially fatal risks of acute stimulant intoxication and psychosis, 24-hour care may be indicated in order to provide the person with adequate supervision and treatment.

Once medically stabilized, the user may be assessed for stimulant addiction and receive appropriate referrals for substance abuse treatment and care. At this time, receiving treatment is critical, as stimulant withdrawal can induce violence and suicidal thoughts. Symptoms of psychosis can persist within the initial few weeks of abstinence.¹⁰

Other concerning stimulant withdrawal symptoms may include:¹⁰

• Intense stimulant cravings.
• Anxiety and irritability.
• Agitation.
• Paranoia.
• Extreme depression.
• Anhedonia, or inability to feel pleasure.
• Insomnia and hypersomnia.
• Extreme fatigue.
• Severe weight loss.
• Dehydration.
• Chills.

Often, a combination of both behavioral and pharmacological approaches can help people struggling with addiction. Today, there are several options available for securing appropriate treatment for stimulant use disorder:¹¹

• Inpatient/residential treatment: Residential treatment can take place in several settings, including hospitals, single-standing private or public addiction facilities, and dual-diagnosis settings. These programs offer highly structured support and around-the-clock monitoring for clients.
• Partial hospitalization/Intensive outpatient treatment: As a common alternative for people with mild-to-moderate substance use disorders, partial hospitalization (PHP) or intensive outpatient (IOP) programs offer structure and support, though clients will typically still work and commute from home. These programs can also exist within hospitals, medical facilities, and addiction centers.
• Medication: Medication-assisted treatment may be integrated into treatment planning to assist with cravings and withdrawal, especially if the user also abuses opioids or alcohol. However, to date, there are no FDA-approved medications for stimulant withdrawal or addiction.

Twelve-step groups, which are often used as an adjunct to formal addiction treatment, provide guidance and support for anyone who wishes to stop using stimulants. Meetings are free and widely accessible throughout the United States. Today, there are many branches of 12-step groups for stimulant or polydrug users, including Narcotics Anonymous (NA), Crystal Meth Anonymous (CMA), and Cocaine Anonymous (CA).

In treatment settings, clients often receive group and individual therapy.¹¹ Both can be highly effective in providing a safe place to explore thoughts and feelings and receive helpful and constructive feedback. Types of therapy include:¹¹

• Cognitive-behavioral therapy (CBT): This helps people identify the connection between their thoughts, feelings, and behaviors and introduces healthier alternatives to maladaptive, drug-seeking behaviors.
• Contingency management: This provides incentives and rewards for positive behaviors, such as avoiding stimulant or drug use.
• Motivational interviewing: This type of therapy increases internal motivation and commitment to specific goals, such as committing to abstinence.
• Matrix model: Matrix Model therapy helps people identify positive change and learn to use effective coping skills and corrective feedback as tools for success. This model is often used in outpatient settings to treat stimulant addiction.

Within the initial stages of treatment, the drug user will collaborate on an appropriate treatment plan for maintaining abstinence and changing their overall attitude and lifestyle surrounding drug use. Aftercare treatment should focus on preventing relapse, managing negative emotions, and implementing positive coping skills for stress management.¹¹

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