Psychosis is often defined as a loss of contact with reality and is generally considered a common symptom of severe mental illness like schizophrenia. Individuals experiencing psychosis may end up dealing with hallucinations (auditory and/or visual), delusions (beliefs with no basis in reality), and an array of other symptoms. While schizophrenia is generally a root cause of psychosis, sometimes psychosis can be induced by stimulant medications.
With an increasing number of individuals being diagnosed with attention-deficit hyperactivity disorders (ADHD), the number of prescription stimulants being doled out is on the rise. Those that use stimulants generally experience increased psychomotor activity, heightened energy, and improved cognitive function. That said, some individuals have certain genetics and neurochemistry that predispose them to a condition known as “stimulant psychosis.”
What is stimulant psychosis?
Stimulant psychosis is a transitory psychiatric condition that occurs among some individuals who use and/or abuse psychostimulant medications or illicit stimulatory drugs. It is most common among individuals who abuse their stimulant prescriptions or take abnormally high doses of an illicit drug such as cocaine or methamphetamines. In fact, the most common drugs associated with inducing stimulant psychosis are: amphetamines and cocaine.
Causes of stimulant psychosis
The most obvious cause of stimulant psychosis is using a potent stimulant, particularly at a high dose. While stimulant psychosis is most often associated with using street drugs like cocaine, and amphetamines like Adderall, even high doses of caffeine could trigger this condition. What causes one person to experience stimulant psychosis and another to remain psychologically unscathed after ingesting the same dosage of the same drug?
Factors that influence stimulant psychosis
There are many factors that may trigger the induction of stimulant psychosis. These factors include: individual neurochemistry and genetics, the specific drug ingested, the dosage of the drug, a person’s stress level, whether they are sleep deprived, as well as whether they have an underlying mental illness.
It is important to consider a person’s individual neurochemistry and genetics as influential factors in cases of stimulant psychosis. Those with abnormal dopamine signaling may be associated with many of the positive symptoms of stimulant psychosis. Although drugs are the underlying cause, a person may be more susceptible than another with dopaminergic abnormalities such as levels in certain parts of the brain and receptor density.
It is also likely that certain genetic abnormalities may influence stimulant psychosis. Genetic expression may dictate neurotransmitter concentrations and brain activity. Ingesting a certain psychostimulant may interact with the expression of these genes, thus inducing a state of psychosis. It is important to realize that dopamine is not the only neurotransmitter involved in stimulant psychosis – a multitude of other chemicals are speculated to play a role.
The dosage of any drug will dictate the effect and side effects that a person experiences. Generally the greater the effect from the drug (as a result of increasing the dose), the more significant the side effect. A majority of people experiencing stimulant psychosis take a dose of a particular stimulant that is too high for their own good.
They overwhelm the nervous system, and their brain cannot function with abnormally high dopamine. While it is still possible to experience stimulant psychosis while taking therapeutic doses of a prescription, these “therapeutic doses” are likely to be on the high side and/or administered to a medication-sensitive individual.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/15764424
3. Drug(s) + Duration
The Drug: Certain drugs are inherently more potent than others. A small amount of methamphetamine is likely going to induce psychosis more than a small amount of caffeine. Both methamphetamine and caffeine can cause stimulant psychosis, but clearly the methamphetamine is more likely to cause psychosis.
Keep in mind that the greater the potency of the stimulant you take, the greater the likelihood that you’ll experience stimulant psychosis. It is also important to realize that combining multiple stimulants may result in a synergistic effect – making the combined effect of the stimulants more powerful than each drug individually.
Duration: It is important to consider that the duration over which a person has taken a stimulatory drug can result in stimulant psychosis. Those that take stimulants for long periods of time may produce psychotic symptoms characterized by hallucinations and delusions. For these individuals it is important to distinguish the fact that continuously taking the stimulant over a long-term was the cause of a transitory psychosis.
Understand that when taken over a long-term, individuals generally increase the dosage (due to tolerance). Taking high doses is known to trigger psychotic symptoms.
4. Stress level
Those that are highly stressed may be more prone than average to stimulant psychosis. This is due to the fact that stress floods the nervous system with cortisol, epinephrine, and other stimulatory chemicals to increase arousal. When stress is high, throwing a stimulant on top of the stress hormones is like dumping gasoline on a roaring fire. This may shock the nervous system, and a person may unexpectedly experience stimulant psychosis.
5. Sleep deprivation
Those that abuse stimulants often go days without proper sleep. A person’s brain functioning takes a major toll when forced to stay awake for a long-term with no rest. Concentrations of neurotransmitters increase after one night of no sleep, particularly dopamine. While receptor concentrations are downregulated, throwing copious doses of stimulants at a person with sleep deprivation is a recipe for stimulant induced psychosis.
6. Mental illness
Most obviously is the fact that if someone has an underlying mental illness, stimulant drugs may be more likely to trigger psychosis. Someone with schizophrenia who ingests a psychostimulant may be quick to experience hallucinations, delusions, etc. as a result of dopamine dysfunction. Even people suffering from certain types of depression or anxiety may be more prone to stimulant psychosis as a result of their underlying psychiatric condition.
List of drugs that may cause stimulant psychosis
There are a variety of drugs that may cause stimulant psychosis – the most common ones are listed below (in alphabetical order).
You’ve maybe heard the term “amphetamine psychosis” which refers to an individual experiencing a psychotic state as a result of ingesting amphetamines. Cases of amphetamine psychosis are most often documented among individuals who abuse or exceed standard doses. Some studies have suggested that nearly 20% of those who use methamphetamine experience stimulant psychosis.
- DOM (STP)
Note: Keep in mind that not all amphetamines in existence are listed above, just some of the most common ones.
Amphetamine Psychosis Symptoms
It is important to understand that there are differences in symptoms of stimulant psychosis that are likely tailored to the specific drug that triggered it. A person taking amphetamines may experience subtle differences in symptoms compared to a person taking cocaine or methylphenidate.
In a review of 168 patients with amphetamine-psychosis, it was discovered that “persecutory delusions” were the most common symptom of methamphetamine-induced psychosis; this occurred in approximately 77% of patients. Second most common was auditory hallucinations at 44% and next strange beliefs and/or visual hallucinations. The analysis clearly noted that amphetamine psychosis didn’t have much in common with negative symptoms of schizophrenia.
- Auditory hallucinations: This is characterized by hearing voices or sounds that aren’t based in reality.
- Delusions of persecution: The most common symptom was that individuals felt as if other people were out to harm, frustrate, or embarrass them.
- Delusions of reference: This refers to a type of delusion in which a person believes that everything they are experiencing has strong personal significance.
- Extreme agitation: Most people with amphetamine-induced psychosis feel extremely agitated and are unable to sit still, due to excess energy.
- Visual hallucinations: Sometimes people may see people, creatures, or things that have no basis in reality.
How long does amphetamine psychosis last?
It is important to realize that recovery rates from amphetamine-induced psychosis are subject to individual variation. For one person it may take a week to achieve full-blown recovery, yet for another it may take up to 30 days. A select number of individuals take longer than 30 days to fully heal from the condition.
- 10 Days: One study from the early 1990s estimated that methamphetamine-psychosis will last approximately 10 days for nearly 60% of individuals upon cessation from the stimulant.
- 30 Days: Those that don’t recover within 10 days, have a good chance of recovering within 30 days (approximately one month). This is assuming that the individual has ceased usage of amphetamines and has remained clean. Nearly 80% of individuals are fully recovered within a month.
- 60 Days: Most people will recover within 60 days of remaining clean from amphetamines and other substances. It is important to understand that even using a small dosage of amphetamines may trigger a relapse.
- Forever: There is some evidence suggesting that a small subset of amphetamine abusers never fully recover over the long-term from amphetamine psychosis. This could be due to continued usage of the amphetamines despite experiencing psychosis, but it may also be due to long-lasting brain changes (e.g. drug-induced dopaminergic dysfunction).
It should be noted that for some individuals, amphetamine abuse may elicit neurochemical changes as well as alter genetic expression, to create a state of permanent schizophrenia. While a permanent drug-induced psychosis is rare, it has been documented. It is believed to occur most frequently in those with a predetermined genetic susceptibility.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/1553491
- Source: http://www.ncbi.nlm.nih.gov/pubmed/1553491
What about during amphetamine withdrawal?
Sometimes people experience amphetamine withdrawal psychosis when discontinuing amphetamines after long-term usage or abuse. Stimulant psychosis can occur even among individuals going through Adderall withdrawal. The difference between a withdrawal-based psychosis and a psychosis stemming from drug usage is that a person withdrawing finds that taking the drug actually reduces symptoms. Among those experiencing stimulant psychosis, taking the drug tends to worsen symptoms.
- Source: https://www.sahealth.sa.gov.au/wps/wcm/connect/cbad29804178755b94d1ff67a94f09f9/Guidelines+methamphetamine-induced+psychosis-DASSA-Oct2013.pdf?MOD=AJPERES&CACHEID=cbad29804178755b94d1ff67a94f09f9
Cocaine has a different mechanism of action than amphetamines, and therefore cocaine-induced psychosis tends to be slightly different. The high from crack cocaine tends to be shorter-lived than that from amphetamines, but both cause significant euphoria and dopamine levels to increase. Total lifetime usage of cocaine has no correlation with increasing risk of cocaine-induced psychosis, but usage of cocaine within the past year does.
Furthermore, the people most susceptible to cocaine psychosis had a longer duration of usage. A sex-based comparison revealed that males were more likely than females to experience cocaine psychosis.
Cocaine Psychosis Symptoms
It is estimated that over 50% of cocaine abusers experience psychotic symptoms. Most commonly, cocaine abusers tend to experience delusions, particularly those related to being persecuted (e.g. monitored) and that they have parasites or bugs in their skin.
- Behavioral stereotypies: Roughly 1 out of every 4 individuals with cocaine psychosis experienced behavioral stereotypies (e.g. rocking, pacing, jumping, etc.).
- Delusional parasitosis: It is common for people to believe they’ve become infested with parasites after abusing cocaine. This type of delusion is often characterized by users believing that parasites have burrowed under their skin. Many people refer to the parasites as “cocaine bugs.”
- Delusions of persecution: Many individuals experiencing cocaine-induced psychosis believe that they are being followed, watched, or that their drug usage is being monitored by someone else.
- Hallucinations: Over 95% of individuals with cocaine psychosis experienced hallucinations during the cocaine-induced psychosis. The hallucinations that occur with cocaine users tend to be directly related to delusions that they’re experiencing.
- Auditory: Nearly 80% of the hallucinations from cocaine usage were auditory, meaning the person heard a voice or sound that wasn’t real.
- Visual: Second most popular was that of visual hallucinations (seeing things that aren’t real) at nearly 40%.
- Tactile: Approximately 20% of individuals with cocaine-induced psychosis experienced tactile hallucinations or felt things that weren’t real.
Note: Symptoms are subject to significant individual variation based on many factors listed above. That said, severity of symptoms tends to worsen with repeated usage of cocaine.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/1752853
- Source: http://www.ncbi.nlm.nih.gov/pubmed/21344286
This is a CNS stimulant medication that is often prescribed for the treatment of ADHD. It often gets falsely clumped with amphetamines, despite the fact that it isn’t an amphetamine. Like other stimulants mentioned, abusing methylphenidate or taking high doses for an extended period of time may induce psychosis. Taking methylphenidate at high doses releases a flood of dopamine at the postsynaptic receptor level, which likely causes the psychotic symptoms.
When taking methylphenidate over a short-term at therapeutic doses, the likelihood of experiencing psychosis is just 1%. That said, it is unclear as to whether long-term, consistent usage of methylphenidate may trigger psychosis among users (especially those with a genetic predisposition to schizophrenia). In a study of nearly 100 children given methylphenidate at therapeutic doses, roughly 6% developed psychotic symptoms.
Methylphenidate Psychosis Symptoms
Those that experience methylphenidate-induced psychosis may experience similar symptoms to those experienced while taking other stimulants like cocaine and amphetamines. Below is a list of symptoms that have been documented.
- Aggression: Some individuals become noticeably more aggressive during their psychotic episode.
- Anxiety: As a result of heightened stimulation and delusions, a person may experience severe anxiety and become fearful and mistrustful of others.
- Auditory hallucinations: Many individuals that experience methylphenidate psychosis hear voices or have other forms of auditory hallucinations.
- Confusion: Often times a person becomes extremely confused while in a state of psychosis. Their speech or thinking may not make much logical sense.
- Delusions: Most commonly reported delusions are those characterized by paranoia. A person may feel as if they are being followed or persecuted by others.
- Grandiosity: Some individuals experience delusions of grandeur in which they believe they are superior to everyone else.
- Mania: This refers to rapid thinking, rapid speech, and an abnormally euphoric mood.
- Irritability: The high energy as a result of the drug’s stimulation can make a person noticeably more irritable than usual during psychosis.
- Visual hallucinations: Some individuals end up seeing things during their psychotic break that aren’t based in reality.
- Self-harm: During a methylphenidate-induced psychotic break, a person may be likely to harm themselves or have urges to harm themselves. The urges may stem from hallucinations, anxiety, and paranoia.
Note: Symptoms listed above will differ based on the individual.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/18978488
- Source: http://www.ncbi.nlm.nih.gov/pubmed/5061074
- Source: http://www.ncbi.nlm.nih.gov/pubmed/20571380
- Source: http://www.journalmc.org/index.php/JMC/article/view/923/517
What about psychosis from methylphenidate withdrawal?
Some individuals experience psychosis when they attempt to discontinue methylphenidate. (Read: Ritalin withdrawal symptoms). This is different from methylphenidate-induced psychosis in that withdrawal-based psychosis can be mitigated by taking more of the drug. A person taking the drug that experiences psychosis will notice more severe symptoms and longer-lasting symptoms if they take more of the drug. If you are experiencing a withdrawal-based psychosis from methylphenidate, it is recommended to taper at a slower rate.
Of all the stimulant drugs capable of inducing psychosis, caffeine is the least likely. However, it is important to consider the fact that some people ingest an abnormally high amount of caffeine on a daily basis. Any stimulant, when taken at a high enough dosage (e.g. abused) has the potential to induce psychosis. While cases of caffeine-induced psychosis are rare, they have been medically documented.
How caffeine may induce psychosis…
Some experts don’t believe that caffeine can cause psychosis, while others believe that only in extremely large doses is caffeine capable of causing psychosis. Keep in mind that life stressors, sleep deprivation, malnourishment, and pre-existing psychosis (or a susceptibility) may make an individual more likely to experience psychosis from caffeine. Some speculate that the mechanism by which caffeine induces psychotic states may be entirely different from classic stimulants.
- Pre-existing psychosis: Those who already have had psychotic breaks or experienced psychosis as a result of a psychiatric condition (e.g. schizophrenia) may be more likely to experience caffeine-induced psychosis.
- Susceptibility to psychosis: If you are a first-degree relative of someone that has experienced psychosis or that has schizophrenia, your susceptibility increases. Large amounts of caffeine may trigger genetic changes that push you into a psychotic state.
- Ridiculously high dose: There is some evidence that when used in highly potent doses over long-terms, caffeine may elicit psychotic symptoms in individuals with no susceptibility to schizophrenia or psychosis. This may be strictly a result of cumulative neurochemical alterations as a result of long-term caffeine abuse.
- Vitamin deficiencies: Some experts believe that an important factor to consider among those that experience caffeine-induced psychosis is that of vitamin deficiencies, particularly various B vitamins. Deficiencies in vitamins and nutrients may increase susceptibility for psychosis.
- Dopamine levels: Caffeine doesn’t directly stimulate the release of dopamine like the other stimulants listed above. In a person with dopaminergic dysfunction as a result of sleep deprivation, poor diet, and/or drug abuse – caffeine may push the brain to a breaking point, resulting in psychosis.
Note: It remains relatively unclear as to what specifically causes caffeine-induced psychosis. That said, it is important to keep in mind that psychosis as a result of caffeine usage is rare compared to other stimulants.
- Source: http://www.ncbi.nlm.nih.gov/pubmed/19407709
- Source: http://www.ncbi.nlm.nih.gov/pubmed/20194494
- Source: http://www.ncbi.nlm.nih.gov/pubmed/15732884
General Symptoms of Stimulant Psychosis
As was mentioned above, the symptoms of stimulant psychosis are subject to individual variation as well as drug variation. Therefore it is nearly impossible to predict exactly what symptom set someone will experience, but it is slightly easier to predict if we know what drug they ingested or abused. Generally stimulant psychosis is characterized by symptoms of organic psychosis (e.g. classic symptoms) accompanied by symptoms resulting from stimulant abuse (e.g. agitation).
If you’re experiencing stimulant psychosis, you’ll likely experience one of several classic symptoms of psychosis.
- Catatonia: Only in extreme cases will a person appear catatonic, unable to move and stuck in a rigid stupor. Realize that this isn’t as common among those experiencing stimulant psychosis due to the fact that stimulants boost energy.
- Delusions: It is common to experience various types of delusions such as those of persecution, grandiosity, and reference.
- Disorganized thinking: Some people display severely disorganized thinking, incoherent behavior, and inappropriate social interactions while experiencing stimulant psychosis.
- Hallucinations: The most common type of hallucinations experienced during stimulant psychosis are auditory (hearing something that isn’t based in reality). After auditory are visual hallucinations (seeing things), followed by tactile (feeling things). In many cases the hallucinations are related to the delusions.
Stimulant Abuse Symptoms
In addition to various symptoms of organic episodes of psychosis, a person with stimulant psychosis will have a variety of physical symptoms. These physical symptoms make it relatively easy to distinguish stimulant psychosis from organic psychosis because they are a result of the heightened stimulation from a drug.
- Pupil dilation
- Rapid breathing
- Sleep deprivation
Distinguishing stimulant psychosis from standard psychosis
It may be difficult for some people to determine whether they are experiencing stimulant psychosis or standard (organic) psychosis. In standard cases of psychosis, the symptoms emerge regardless if the person uses the drugs and/or stops using the drugs. In the case of stimulant psychosis, the psychotic symptoms tend to subside within 30 days of sobriety – remaining free of the stimulant.
In rare cases among those with a genetic susceptibility to psychosis will stimulant psychosis lead to permanent psychotic break. This permanent psychosis only occurs in approximately 5% to 10% of all individuals that experience stimulant psychosis. It should be noted that in some cases, it may take much longer than a couple months to fully recover from the stimulant-induced psychotic episode.
Stimulant Psychosis Treatment
There are some successful treatment strategies for those experiencing stimulant psychosis. The most effective treatment for mitigating psychotic symptoms is a low dose atypical antipsychotic. As an alternative or adjunct to atypical antipsychotics, some practitioners may utilize benzodiazepines or other CNS depressants to reduce stimulatory activity in the CNS.
In the acute stages of stimulant psychosis, it is best if the patient is kept under medical supervision. This supervision will help monitor and control any changes in blood pressure, body temperature, and heart rate. Stimulants taken at high doses often can increase blood pressure, body temperature, and lead to heart rate abnormalities. A person may also may end up severely dehydrated.
- Blood pressure
- Body temperature
- Heart rate
Medications and therapy
The most commonly prescribed medications for the treatment of stimulant psychosis are antipsychotics. Sometimes benzodiazepines are added to the treatment equation and CBT (psychotherapy) is utilized to enhance recovery.
Antipsychotics: Some studies suggest that administration of atypical (newer) antipsychotics is the most effective treatment for stimulant psychosis. Injections of atypical antipsychotics (e.g. olanzapine) are considered well-tolerated and can decrease symptoms of stimulant psychosis within an hour. Older antipsychotics are less expensive, but tend to have significantly more unfavorable side effects – therefore newer options are preferred; often at a low dose.
Benzodiazepines: In some cases low doses of benzodiazepines may be administered to counteract the effects of the stimulants. Benzos are known to decrease activity in the CNS and inhibit stimulation by increasing the neurotransmitter GABA.
CBT: For severe cases of stimulant psychosis, a person may require extensive cognitive-behavioral therapy to cope with the psychotic symptoms that they’re experiencing. A skilled therapist will help guide the patient through their symptoms and differentiate the symptoms from reality. This will allow for a smoother transition back to “reality” from “psychosis.”
- Source: http://www.ncbi.nlm.nih.gov/pubmed/15339823
- Source: http://www.ncbi.nlm.nih.gov/pubmed/19160215
- Source: http://www.ncbi.nlm.nih.gov/pubmed/11687172
Have you experienced stimulant psychosis?
If you’ve taken any of the stimulants listed above (e.g. amphetamines, cocaine, methylphenidate, caffeine, etc.) and experienced “stimulant psychosis” feel free to share your experience in the comments section below. Discuss the symptoms you experienced, the drug (or multiple drugs) you took that caused it, as well as the dosage you were taking. To help others get a better idea of your situation you may want to mention how long the psychosis lasted and what you did to overcome or mitigate certain symptoms.