Psychiatry · Year 2 · from Psychiatry
Case 3: Stimulant Use Disorder with Psychosis
Patient Presentation
Demographics: 35-year-old male
Chief Complaint: Brought by police after found yelling at traffic, extremely agitated
History of Present Illness: A 35-year-old man is brought to the emergency department by police after being found in the middle of an intersection, yelling about people trying to kill him. He is extremely agitated and paranoid, believing the police are part of a conspiracy. According to friends contacted later, he has been using methamphetamine heavily for the past 3 weeks during a "binge," sleeping only a few hours total. He has used methamphetamine intermittently for 5 years but increased use dramatically after losing his job 6 months ago. He has no prior psychiatric history and no psychotic symptoms when not using methamphetamine. He has been picking at his skin, believing there are "bugs under the skin."
Physical Examination:
- Vital signs: BP 182/110, HR 142, T 38.4C, RR 24
- General: Diaphoretic, extremely agitated male, appears emaciated
- Pupils: 7 mm, reactive
- Skin: Multiple excoriations on arms and face from picking
- Cardiac: Tachycardic, no murmurs
- Dental: Extensive decay ("meth mouth")
Mental Status Examination:
- Appearance: Disheveled, emaciated, multiple skin lesions
- Behavior: Extremely agitated, combative, attempting to leave
- Speech: Rapid, pressured, incoherent at times
- Mood: "They're trying to kill me"
- Affect: Terrified, agitated
- Thought content: Paranoid delusions (conspiracy, being followed), formication (bugs under skin)
- Perceptions: Tactile hallucinations (formication), possible visual hallucinations
- Cognition: Unable to assess due to agitation
- Insight/Judgment: Absent/Absent
Workup:
- Urine drug screen: Positive for amphetamines
- CMP: Sodium 132, potassium 3.2, creatinine 1.4 (dehydrated)
- CPK: 2,800 U/L (elevated - rhabdomyolysis risk)
- ECG: Sinus tachycardia, no ischemia
- Troponin: Negative
- CT head: No acute abnormality
- Blood glucose: 82 mg/dL
Diagnosis: Stimulant Use Disorder (Methamphetamine), severe; Substance-Induced Psychotic Disorder
Treatment:
- IV access obtained with mild sedation
- Lorazepam 2 mg IV for agitation (benzodiazepines first-line for stimulant intoxication)
- Additional doses given PRN for continued agitation
- Avoided antipsychotics initially due to hyperthermia and risk of lowering seizure threshold
- Aggressive IV hydration for dehydration and rhabdomyolysis prophylaxis
- Cooling measures for hyperthermia
- Monitored on telemetry for arrhythmias
- Day 2: Calmer after sleep, psychotic symptoms significantly improved
- Day 3: Psychosis resolved with sleep and cessation of stimulant
- Started supportive care for stimulant withdrawal (hypersomnia, depression)
- No medications FDA-approved for stimulant use disorder - psychosocial treatment is primary
- Referred to intensive outpatient program with contingency management
- Dental evaluation for extensive decay
- Dermatology follow-up for excoriation wounds
- Discharged day 5, psychiatrically stable
Clinical Pearl: Stimulant-induced psychosis typically resolves within days to a week of cessation with supportive care, distinguishing it from primary psychotic disorders. Formication (sensation of bugs crawling on or under the skin) is characteristic of stimulant-induced psychosis. Benzodiazepines are first-line for stimulant intoxication agitation. There are no FDA-approved medications for stimulant use disorder - treatment relies on psychosocial interventions, with contingency management having the strongest evidence. Stimulant withdrawal causes a "crash" with hypersomnia, hyperphagia, and depression.
Clinical Image
Image Description: Before and after photographs demonstrating the physical effects of chronic methamphetamine use, including dramatic facial aging, skin lesions from picking, dental decay (meth mouth), and weight loss. These images are used in public health campaigns to demonstrate the devastating physical consequences of methamphetamine use.
Attribution: Public domain image from US Department of Justice, Faces of Meth campaign, used for educational purposes about substance abuse.
Image Source: Wikimedia Commons - https://commons.wikimedia.org/wiki/Category:Methamphetamine - Search for "faces of meth" or "methamphetamine effects"