Case submitted by: Mary Ann Barnovitz, MD, psychiatry and internal medicine resident in northern California
Psychiatric consultant: Jaesu Han, MD, assistant clinical professor, departments of psychiatry and family medicine, University of California, Davis.
Starting as a regional problem in the southwestern states, methamphetamine abuse has spread to the rest of the country.1 Commonly known as “ice,” “speed,” “crank,” or “crystal”—to name a few—this synthetically derived stimulant can be used intranasally, swallowed, injected, smoked, or mixed with other drugs.
This case illustrates the type of diagnostic dilemma primary care physicians can see in chronic methamphetamine users. We offer this dialogue to help generalist psychiatrists asked for consultation to unravel the manic, depressive, and substance abuse symptoms that characterize long-term methamphetamine addiction.
Dr. Barnovitz’ patient: Addicted to ‘meth’
Mr. N, age 26, presented at the county outpatient clinic with a history of daily intranasal methamphetamine use. He told me, “I feel like I’m losing my mind and see no reason to go on.” He reported feeling depressed for 7 years and said his primary problem is, “no energy and no hope that things will improve.”
Mr. N complained of decreased concentration, and appetite as well as chronic insomnia. He takes no medications and denies drug allergies. He has no history of tobacco, alcohol, or other illicit drug use. He lives with his ex-girlfriend and has been unemployed for 1 month.
For the past 2 weeks he has been unable to speak slowly, and his thoughts have been “racing too fast to focus.” When I contacted his family (with his permission), they said he is paranoid and persistently claims the FBI is “monitoring his every move.”
Medical history. Mr. N has never been treated for psychiatric conditions. He denies auditory, visual, or tactile hallucinations and has no other medical problems. He has used methamphetamines for 5 years, with no period of sobriety. He said, “I don’t think I have a problem with drugs and see no reason to stop using.” Because of escalating relationship problems with his ex-girlfriend, he reported more-frequent methamphetamine use during the weeks before this assessment.
Physical exam. Mr. N was anxious and hypervigilant, with marked psychomotor agitation. He was otherwise well-related and described his mood as “really down,” with a corresponding labile affect. Vital signs were stable with a pulse of 114 bpm. Neurologic, cardiovascular, pulmonary, and abdominal exam results were normal.
Initial treatment. Despite his depression, I did not think Mr. N warranted psychiatric admission. I started him on paroxetine, 20 mg/d, and referred him for drug rehabilitation.
One week later, Mr. N’s family called me with concerns about his worsening insomnia, depression, paranoid thoughts, and suicidal ideation. I would like help determining if this patient should be admitted for psychiatric evaluation and if symptoms are likely caused by methamphetamine abuse or suggest other psychiatric disorders.
Dr. Han’s consultation
Because of Mr. N’s worsening symptoms and suicidal ideation, I strongly recommend evaluation for inpatient psychiatric hospitalization to allow for methamphetamine detoxification in a safe environment. Ideally, psychotropics would be held and the patient’s mood and psychotic symptoms would improve in a few days, confirming the diagnosis of methamphetamine intoxication.
Acute methamphetamine intoxication (Table 1) is associated with euphoria, talkativeness, and psychomotor agitation that can resemble the manic or mixed phase of bipolar disorder. Methamphetamine withdrawal (Table 2) is associated with dysphoric mood, disturbed sleep, and psychomotor changes that can resemble depression.
Close examination shows Mr. N fulfills criteria for:
- a major depressive episode (feeling depressed for 7 years, decreased energy, decreased concentration, insomnia)
- a manic episode (irritability, pressured speech, racing thoughts, psychomotor agitation, possibly decreased need for sleep).
His contention that the FBI is “monitoring his every move” also introduces a psychotic element.
Mr. N’s presenting diagnosis is amphetamine dependence with a provisional diagnosis of methamphetamine intoxication. Because of ongoing “meth” use, remaining diagnoses to rule out include bipolar disorder, mixed episode with psychotic features, and severe major depression with psychotic features. The drug-induced changes could also be aggravating a primary mood disorder. Obtaining a urine toxicology screen would help document recent intoxication.
Table 1
Symptoms of amphetamine intoxication
| Behavioral |
| Euphoria or affective blunting |
| Changes in sociability |
| Hypervigilance or interpersonal sensitivity |
| Anxiety, tension, or anger |
| Stereotyped behaviors |
| Impaired judgment |
| Impaired social or occupational functioning |
| Physiologic |
| Tachycardia or bradycardia |
| Pupillary dilation |
| Elevated or lowered blood pressure |
| Perspiration or chills |
| Nausea or vomiting |
| Evidence of weight loss |
| Psychomotor agitation or retardation |
| Muscular weakness, respiratory depression, chest pain, or cardiac arrythmias |
| Confusion, seizures, dyskinesias, dystonias, or coma |
| Source: Diagnostic and statistical manual of mental disorders, 4th ed., text rev. |
Table 2
Symptoms of amphetamine withdrawal
| Dysphoric mood |
| Fatigue |
| Vivid, unpleasant dreams |
| Insomnia or hypersomnia |
| Increased appetite |
| Psychomotor retardation or agitation |
| Source: Diagnostic and statistical manual of mental disorders, 4th ed., text rev. |