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Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
Clinical Diagnostic Considerations on Cocaine Abuse a
George B. Palermo & Mark T. Palermo
a
a
Medical College of Wisconsin , Milwaukee , Wisconsin Published online: 20 Jan 2012.
To cite this article: George B. Palermo & Mark T. Palermo (1990) Clinical Diagnostic Considerations on Cocaine Abuse, Journal of Psychoactive Drugs, 22:3, 313-318, DOI: 10.1080/02791072.1990.10472554 To link to this article: http://dx.doi.org/10.1080/02791072.1990.10472554
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Clinical Diagnostic Considerations on Cocaine Abuse
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George B. Palermo, M.D. * & Mark T. Palermo, M.D. ** Abstract - Following a review of the resear ch literature on the psychophysiological effects of cocaine, a study is described of a group of 120 cocaine addicts. Of the 120 patients, 10 (8.33%) exhibited fleeting, unformed, organic delusions and hallucinations . Case reports of the 10 cases are presented. The quality of the adverse subjective effects of cocaine is emphasized, and the differential diagnosis between Cocaine Delusional Disorder and Paranoid Schizophrenia is discussed. Guidelines for a more accurate differential diagnosis are prov ided. Keywords - cocaine abuse, cocaine delusional disorder, differential diagnosis, paranoid schizophrenia
Modem psychopharmacology may have begun with Freud's use of cocaine (Barchas et al. 1977). In 1884, Freud wrote (Jones 1953), "In my last severe depression, I took cocaine again and a small dose lifted me to the heights in a wonderful fashion I take very small doses of it regularly against depression with the most brilliant success." The few unfortunate experiences that he later encountered with cocaine may have contributed to the long-standing prejudice of the psychoanalytic group against psychopharmacology. Most of the research studies and clinical observations support the idea that the use of cocaine, usually by snorting , smoking or injecting, is followed by a progression of clinical syndromes: euphoria and hyperactivity, depres sion or dysphoria, paranoid reaction, and eventually psychosis. It is further accepted that the dosage and the chronic use of the drug are the primary factors for the development of the above manifestations (Post 1975). Genetic or premorbid psychopathology are important cofactors . Kindling (i.e., arousal phenomenon) facilitated by cocaine, as well as by amphetamines, has been proposed and researched extensively and magisterially by Post and Kopanda (1976). It is at the level of the limbic system-
a system of subcortical structures, including the amygdala, the hippocampus, and septal regions - that kindling originates. These anatomical structures are not only involved in the limbic ictus (also known as episodic discontrol) but also in transient behavior of a confused type. Continuous or intermittent stimulation of the amygdala in laboratory animals produces either rapid neuronal exhaustion or a kindling effect (Monroe 1982). The physiology of the limbic system can be altered not only by electrical and chemical stimulation but also by intrapsychic distress caused by the memory of adverse experiences; stress could be at the basis of the flashbacks reported by many former stimulant addicts. Episodic neurophysiological dysfunction of the limbic system, generally of short duration, may also be involved in schizophrenic reactions. Cocaine is a potent psychomotor stimulant in humans and generates behavior characterized by meticulous and repetitious arrangement of objects. According to Post (1975), "The user, paranoid, has a clear sensorium and is not con fused or disoriented. . .. Stereotype, compulsive behavior . . . can develop.... Addicts ... repetitively pursue the same task ... endlessly absorbed by minutiae." Cocaine affects neurotransmitters by blocking the synaptic reuptake of norepinephrine and dopamine, while its action on serotonin neurons is largely inhibitory. It is a potent inhibitor of monoamine reuptake at the synapse, but without any significant antidepressant activity (Barchas et al. 1977) . Reverse tolerance, potentiating the effect of catecholamines at the synapse, is produced by repetitious administration of even small doses of cocaine (Dackis & Gold 1988).
• Associate Professor of Clinical Psychiatry, Medical College of Wisconsin, Milwaukee, Wiscons in; Senior Psychia trist, Milwaukee County Mental Health Complex and DePaul Drug and Alcohol Rehabilitation Hospital, Milwaukee, Wisconsin . • · Psychiatty Resident, Medical College of Wisconsin, Milwaukee, Wisconsin . Please address reprint requests to George B. Palermo, M.D., 925 East Wells, No. 316, Milwaukee, Wisconsin 53202 . Journal ofPsychoactive Drugs
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Diagnostic Considerations on Cocaine Abuse
is the possibility that the cocaine market is moving into suburban and rural areas of the United States (Backer 1987). A decline in the use of cocaine among high-school seniors and young adults was reported for 1987 (Unsigned 1988).
Resnick and Resnick (1984) and Post (1975) stated that cocaine may produce a variety of psychiatric syndromes. At times, cocaine-induced paranoia and hallucinations may lead to violent behavior, both homicidal or suicidal. Typically, shortly after using cocaine, the user suddenly becomes paranoid. Hyperexcitability and bizarre behavior are often present. In a study reported by Spitz and Rosecan (1987), 57% of the users experienced psychiatric symptoms marked by irritability, socially disruptive behavior, omnipotent feelings , suspiciousness, and hallucinations. Studies by Climent and Aragon (1984), Jeri (1984), and Washton and Tatarsky (1984) showed that cocaine abusers developed symptoms of irritability, paranoid feelings, hostility, hallucinations, and suicidal ideation. Post and Kopanda (1976) stated that "when cocaine is abused chronically, paranoid psychosis ... can result. After acute intravenous cocaine administration the development of a paranoid psychotic state (referred to by users as the bull horrors because of the intense fear of police) can occur. ... After chronic cocaine administration delusions of persecution may be vague .... Suspiciousness normally follows long term usc. " Cocaine addiction also generates compulsive behavior. Laboratory animals prefer the ingestion of cocaine to food, water, sleep or sex, and continue to do so in the face of aversive punishment and debilitation (pollack, Brotman & Rosenbaum 1989). Furthermore, cocaine remains rewarding even when administered at toxic levels (Fisher, Raskin & Uhlenhuth 1987). An experimental study by Sherer (1988) showed that "as the cocaine infusion progressed, increasing focused suspicious behavior was evident to the point of overt paranoia . Psychiatric symptoms usually dissipated within hours." In a study by Erickson and colleagues (1987), 23% of the participants reported feelings of suspiciousness. Cocaine usc increased markedly between 1974 and 1985 (pollack, Brotman & Rosenbaum 1989). In 1974, 5.4 million Americans admitted to having tried cocaine at least once; by 1985,22 million had tried it. The decreased price and increased availability of the drug, especially in the form of free-base cocaine (crack), has made it accessible to people of all ages, races, and socioeconomic classes. There were 190 cocaine-related deaths in 1981; by 1984 that figure had risen to 578. In that year, NIDA declared cocaine the drug of greatest concern (pollin 1984). A substantial increase in cocaine psychosis has also been seen at the Haight Ashbury Free Clinics, as a consequence of the increasing use of free-base cocaine (Smith 1986). A recent NIDA survey on the cocaine epidemic in the United States showed no significant increase in cocaine usc during 1989 in New York, Philadelphia, New Orleans, and Washington, D.C. (Unsigned 1990). However, there Journal of Psychoactive Drugs
CASE STUDIES The present authors extensively reviewed the literature regarding cocaine paranoid reaction. Moreover, DSM-III-R (p. 143) currently describes the syndrome Cocaine Delusional Disorder as an Organic Delusional Syndrome appearing shortly after the use of cocaine. It states that the syndrome develops shortly after the use of cocaine and that persecutory delusions arc the predominant clinical feature lasting for a week or longer, but occasionally for over a year. No detailed description of the quality of the delusions and hallucinations experienced by the paranoid cocaine addict was found either in the literature or in DSM-II1-R. This lack of information has prompted further investigation of these symptoms by the present authors in the hope of finding a consistent basis that would enable clinicians to better differentiate the cocaine paranoid reaction from paranoid schizophrenia. In the present study, the diagnostic category Cocaine Paranoid Reaction is interchangeable with Cocaine Delusional Disorder in DSM-III-R . A group of 120 patients, who had used cocaine for periods ranging from one to 12 years, was examined at the DePaul Drug and Alcohol Rehabilitation Hospital in Milwaukee and at the Milwaukee County Mental Health Complex Forensic Unit. Of the 120 patients, 10 (8.33%) exhibited persecutory ideas in addition to the vague suspiciousness that is usually present in cocaine addicts. Previously, five of these 10 patients had been diagnosed by private practitioners or by clinicians at local community psychiatric hospitals as suffering from paranoid schizophrenia. During the first 72 hours, the treatment of the 10 patients included in the study was limited to milieusupportive therapy, and no psychotropic medication was used during the first week. Four case examples are provided below. Case 1 T.e. is a 22-year-old Black male who came to the hospital asking for help because of auditory hallucinations and feelings of persecution. Two years earlier, in a psychiatric hospital in Milwaukee, he had been diagnosed as suffering from paranoid schizophrenia. His ideas of persecution were extremely vague: "People are against me. They are trying to do something against me. I don't know who they are ." The auditory hallucinations consisted of a "whispering voice." Psychomotor agitation was present. His sensorium was clear and he made good eye contact. 314
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He had a six-year history of addiction to snorting and smoking cocaine. A diagnosis of paranoid reaction due to cocaine was made. After 36 hours, the patient's symptomatology abated.
with which they were threatening him. The type of hallucinations was expressed as follows: "I hear a voice in my head talking to me." He showed good eye contact and some restlessness. He described the usual Magnan formication. A diagnosis of paranoid reaction due to cocaine was made. He was free from his delusions and hallucinations 36 hours later.
Case 2 W.T. is a 24-year-old Black male who came to the hospital because he could no longer tolerate his four-year cocaine addiction. A year earlier he had been diagnosed, in another mental health care institution in Milwaukee, as a paranoid schizophrenic with manic features. He was talkative, slightly exuberant, and showed good eye contact. His paranoid ideation consisted of "people and the police are after me." His auditory hallucinations were described as "whispering sounds." His sensorium was clear. He expressed his wish to get help. A diagnosis of Paranoid Cocaine Reaction was made. Two days later he was free from his paranoid ideation.
DIFFERENTIAL DIAGNOSIS The vagueness, concreteness, and meagerness of the so-called delusions and hallucinations exhibited by the cocaine addict suffering from a delusional disorder make them akin to the secondary delusions described by Jaspers (1963). The delusional ideas could easily be understood as elaborations of affectively important events in the patients' present lives. The patients in the present study had delusions that were concrete, unformed, vague, and persecutory in quality: "People are against me. They are trying to do something to me. I don't know who they are." Paranoid ideation in these patients usually disappeared within 24 to 48 hours. Shick (1985) has reported that "suicidal preoccupation and paranoid ideation among cocaine abusers tended to disappear more rapidly than [was] originally envisioned, usually within the first 24 hours of admission." The patients in the present study felt pervasive suspiciousness punctuated by distressing paranoid delusions. They believed that others were "spying on me" or "out to get me." The patients who suffered from Cocaine Paranoid Reaction always exhibited a certain restlessness and psychomotor agitation. The patients' vague paranoid ideation, restless hypervigilant behavior, and purposeless agitation are quite in contrast with the classic picture of paranoid schizophrenia. For example, in his classic work Textbook ofPsychiatry, Bleuler (1934) stated that "one speaks of a defect in the emotional rapport, which is an important sign of schizophrenia. One feels emotionalIy more in touch with an idiot who does not utter a word than with a schizophrenic who can still converse well, intellectually, but who is inwardly unapproachable." Again, referring to schizophrenia, he stated that "there is a loss of affectivity or indifference." However, the paranoid behavior of cocaine addicts shows a certain obsessive searching for the fantasized persecutors. As the wife of a patient told one of the authors (G. Palermo), "For hours my husband, while under the effect of cocaine, had the shades in our bedroom windows pulled down and was peeking out of the window in an obsessive search for unidentified people supposedly after him. At times he spoke of the police and neighbors." The visual hallucinations described by the patients in the present study group appeared as gross misinterpretations of reality, with abstract images and alterations of color, size, and shape, which are typical of an organic ori-
Case 3 J.S., a 26-year-old White female, was examined in the Milwaukee County Jail by one of the authors (G. Palermo) on the request of the jail's nursing office. She was agitated, her affect was minimally depressed, she was suspicious, and had paranoid ideation. Her medical history revealed that two years earlier a diagnosis of schizo-affective reaction with paranoid ideation had been made by a local psychiatrist in private practice. She showed normal prosody and a sad, depressed look . She exhibited psychomotor agitation but had good eye contact. During the previous four years, she had been using half an ounce of cocaine daily by snorting, smoking, and intravenous injection. Occasional alcohol abuse also occurred. She experienced paranoid ideation, claiming that people in general and police undercover agents were watching her. She also had unformed auditory hallucinations in which she heard unintelligible words. She was asking for help. A diagnosis of Paranoid Cocaine Reaction was made. Forty hours later she was free from paranoid ideation and auditory haIlucinations. Case 4 J.e. is a 29-year-old Black male who, while being examined, stated that "I am tired of the way I am living. 1 can't keep no job, no money, and 1 don't know what is going on ." Three years earlier he had been diagnosed at a local psychiatric hospital as suffering from schizophrenia; Haldol and Cogentin were prescribed during his hospitalization. His medical history also revealed an addiction to cocaine, with daily use ("As often as 1can get money.") for the previous six years. His paranoid ideation consisted of "people are against me and are trying to do something to me." He was unable to identify the people. He was fearful of them, but he was unable to state the type of harm Journal of Psychoactive Drugs
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"psychotic symptoms and depression are usually brief and remit following prolonged sleep, but may require observation and suicide prevention.... Counseling or psychotherapy are usually employed." In addition, Estroff (1987) has pointed out that " the cocaine addict has sufficient reality testing left to realize that his perceptions are not correct, despite the experience of paranoid thoughts and auditory hallucinations." The reality testing of the patients in the present study was fairly good, while the reality testing of paranoid schizophrenics is quite poor. Estroff also stated that "knowing that their symptoms are not real they have enough self-control not to act on their psychotic symptoms, but this docs not keep them from constantly checking their environment. They remain hypervigilant, often staring out of a window for hours, watching for the police, for the F.B.I., believing that they are 'out to get me."' Gawin (1986) reported two cases of paranoid reaction due to cocaine. Both of the addicts' delusions centered around their possible persecution by either federal drug enforcement agents or imaginary drug dealers. These patients recovered rapidly - within one day of ending a cocaine binge. In addition to a rapid recovery period, the present authors' clinical experience has shown that addicts who have recovered from a previous Delusional Disorder due to cocaine usually have a clear recollection of their paranoid ideation and hallucinatory experiences. Finally, it should not be forgotten that cocaine abusers may be self-medicating a psychiatric disorder, and a dual diagnosis may be indicated .
gin according to DSM-Ill-R. In these cases.the auditory hallucinations were mostly poorly defined noises, music, whispering or indistinct voices: tinnitus and buzzing were heard at times, and the voices had an obsessive quality. The schizophrenic splitting between thought and affect described by Bleuler was never observed in the patients in the present study group. When relating the pseudoparanoid ideas, the patients did not show the flatness of affect or emotional detachment that Bleuler portrayed. Their affect was at unison with the content of their thinking. Insight (i.e., the realization of being in an abnormal condition), which is absent in the schizophrenic reaction except in some initial phases, was present in the patients in the present study. The age of the patients should be taken into consideration. As Arieti (I 959) stated in his Handbook on Psychiatry, "Onset of paranoid schizophrenia usually occurs a lillie later in life than other types. It is more common in the fourth and fifth decades." On the contrary, the patients in the present study were in their twenties and thirties. In Modern Clinical Psychiatry, Noyes and Kolb (I958) stated that paranoid schizophrenia "occurs most frequently after thirty years of age." In support of a later onset of Paranoid Schizophrenia, as opposed to that of Cocaine Delusional Reaction , DSM-lll-R (p. 197) clearly indicates that "onset of paranoid schizophrenia tends to be later in life that the other types." In addition, DSM-lll-R states that "occupational functioning and capacity for independent living is considerably better than other types of schizophrenia." Instead, the paticnts in the present study were unable to function and they had lost their capacity for independent living. Their hyperactivity, ritualistic stereotyped behavior, paranoid suspiciousness and delusional ideas impeded them from properly and gainfully involving themselves in the business oflife. Usually, paranoid schizophrenics are not only irritable, resentful, discontented , and angrily suspicious, but they show a surly aversion to being interviewed. The cocaine-paranoid patients, on the contrary, showed an intense desire for communication and help. Their premorbid personality was not that of a schizoid, but that of a sociopathic personality that has been abusing drugs in excess, especially cocaine, for many years. However, Weiss and Mirin (1987) reported that 90% of39 hospitalized chronic cocaine abusers met DSM-lIl-R criteria for Personality Disorder, Borderline or Narcissistic type, and only three percent met criteria for Antisocial Personality. The recovery period of the cocaine addict suffering from a delusional persecutory disorder is also remarkably short, unlike the paranoid schizophrenic. He or she usually recovers from the delusions promptly and without medication. At times, within a period as short as 24 hours to a maximum of five days, his or her pseudoparanoid ideation completely disappears . Wang (1987) stated that Journal of Psy choactive Drugs
CONCLUSIONS AND RECOMMENDATIONS
Delusional persecutory disorder due to cocaine is a rare, self-limited entity. Its disappearance is quite sudden and dramatic, usually after a 24-48 hour cocaine-free period. In order not to throw the cocaine addict suffering from a delusional disorder of a persecutory type into the large cauldron of paranoid schizophrenia, the following recommendations arc made: I. A period of observation (maximum 48 hours), possibly without prescribing psychotropic medication, would allow the patient to return to his or her normal selfbecausc of the very short half-life of cocaine in the blood. 2. A thorough history should be taken and a physical examination should be performed. The patient should be specifically questioned regarding the use of cocaine (i.c., for how long, how much, and how often). A urine test for cocaine should be a routine procedure. The clinician should gather specific information as to when the symptoms began and their relationship to possible alcohol or other drug intake. The clinician should also inquire about masturbatory rituals, coke bugs, paranoia, and vi316
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3. 4.
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S.
6.
7.
8.
9.
a clearer state of mind, free from delusions and hallucinations. 10.A reassessment of the patient's behavior as well as mental andphysical status at the end of24 hours and for three consecutive days is mandatory. 11. A straitjacket of psychotropic medication should be avoided because it would only complicate the differential diagnosis. By following these recommendations, the differential diagnosis between paranoid schizophrenia and a delusional syndrome due to cocaine abuse may be facilitated, and the erroneous labeling of the cocaine addict with paranoid reaction as paranoid schizophrenic would not ensue. Misdiagnosing a patient with a Cocaine Delusional Reaction as schizophrenic-paranoid type could have present and future consequences for his or her therapy and rehabilitation. Clinicians should always remember the Hippocratic dictums, "Observation win always lead to proper diagnosis" and "Nature has its own healing power." However, a very cautious, supportive pharmacological intervention may, at times, be necessary. Counseling and milieu therapy are of paramount importance. Clinical observation of patients over a long period of time and numerous scientific studies have proven cocaine to be utterly disturbing to the human mind and profoundly disruptive to society. As Cohen (1985) aptly stated, "Cocaine is . .. an entrapping agent that promises happiness and, in the end, offers nothing but disaster."
sual hallucinations as wel1 as look for the presence of mydriasis (i.e ., cocaine-induced enhancement of norepinephrine that potentiates the action of the sympathetic fibers that innervate the radial muscle of the iris). An inquiry should be made regarding any psychiatric illness preceding the addiction. Friends and relatives of the patient should be interviewed, if possible. The paranoid patient should be asked to accurately describe the quality of delusions or hal1ucinations from which he or she may suffer, in order to elicit the presence of unformed pseudodelusions or organic auditory hal1ucinationstypical of cocaine intoxication. The affectivity of the patient should be given due attention, as there is no flatness of affect in the cocaine paranoid patient. The presence of psychomotor agitation in a delusional patient and his or her insistent search for communication and help should alert the clinician that a toxic reaction to cocaine is present rather than paranoid schizophrenia. An important differentiating factor is the age of the patient: the patient suffering from a delusional persecutory disorder due to cocaine is usually much younger than the paranoid schizophrenic. The recovery time should be monitored. Indeed, a good night's sleep without cocaine may be enough to return the cocaine paranoid patient to
REFERENCES but not euphoria. Psy chopharmacology Vol. 90: 142-143 . Jaspers , K. 1963. General Psychopathology. Chicago: University of Chicago Press . Jeri, ER . 1984. Coca paste smoking in Latin America: A review of a severe and unabated form of addiction . Bulletin on Narcotics Vol. 36: 15-32. Jones, E. 1953. The cocaine episode. In: Trilling, L & Marcus, S. (Eds.) The Life and Work ofSigmund Freud. New York: Basic Books . Monroe , R.R. 1982. Limbic ictus and atypical psychosis. Journal of Nervous and Menial Disease Vol. 170: 711-716. Noyes, A.P. & Kolb, L.C . 1958. Modern Clinical Psychiatry. Philadelphia: W.B. Saunders. Pollack, M.H.; Brotman, A.W. & Rosenbaum, J.E 1989. Cocaine Abuse and Treatment, New York: Grone & Stratton. Pollin, W. 1984 . Foreword. In : Grabowski, J. (Ed .) Coca ine : Pharmacology, Effects, and Treatment of Abuse . NIDA Research Monograph 50. Rockville, Maryland: NIDA . Post, R.M. 1975. Cocaine psychosis: A continuum model. American Journal of Psychiatry Vol. 132: 225-231. Post, R.M. & Kopanda, R.T. 1976. Cocaine, kindling and psychosis. American Journal ofPsychiatry Vol. 133: 627-634. Resnick, R.B. & Resnick , E.B. 1984. Cocaine abuse and its treatment. Psychiatric Clinics ofNorth America Vol. 7: 713-728. Sherer, M.A. 1988. Intravenous cocaine: Psychiatric effects , biological mechanisms. B iological Psychiatry Vol. 24 : 865-885 .
Arieti , S. 1959. American Handbook ofPsych iatry . Vol. 1. New York: Basic Books . Backer, T.E. 1987 . Strategic Planning for Workplace Drug Abuse Program. Rockville, Maryland: NIDA. Barchas, J.D .; Berger. R.D.; Cia ranello, R.D . & Elliot, G.R . 1977. Psy chopharmacology. New York: Oxford University Press. Bleuler, E. 1934. Textbook ofPsychiatry. New York: Macmillan. Oiment, C.E. & Aragon, LV. 1984. Clinical aspects of coca paste smoking (basuco) in Columbia. Paper presented at WHO Advisory Group Meeting on the Adverse Health Consequences of Cocaine and Coca Paste Smoking, Bogota . Cohen, S. 1985. Cocaine: Myths and consequences. In: Brink, C.J. (Ed.) Cocaine: A Symposium. Sponsored by the Wisconsin Institute on Drug Abuse and NIDA . Madison : Wisconsin Institute on Drug Abuse. Dackis, C.A. & Gold , M.S. 1988. Psychopharmacology of cocaine. Psychiatric Annals Vol. 18: 529 . Erickson, P.G.; Adlaf, M.E.; Murray, G.E & Smart, R.G. 1987. The Steel Drug . Lexington, Massachusetts : Lexington Books. Estroff, T.W. 1987. Medical and biological consequences of cocaine abuse. In : Washton, A.M . & Gold, M.S . (Eds.) Cocaine - A Clinician's Handbook. New York: Guilford. Fisher, S.; Raskin, A. & Uhlenhuth, E.H. 1987. Cocaine: Clinical and Biochemical Aspects. New York: Oxford University Press. Gawin, EH . 1986. Neuroleptic reduction of cocaine induced paranoia
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Diagnostic Considerations on Cocaine Abuse Unsigned. 1988. Government campaign to halt drug abuse beginning to show some success. Psychiatric News Vol. 23 : 17. Wang, R.I . 1987. Practical Drug Therapy. Milwaukee: Meadstream Press. Washton, A.M. & Tatarsky, A. 1984. Adverse effects of cocaine abuse. In: Harris, LS. (Ed.) Problems ofDrug Dependence. 1983 . NIDA Research Monograph 49. Rockville, Maryland: NIDA. Weiss, R.D. & Mirin, S.W. 1987. Cocaine . Washington, D.C. : American Psychiatric Press.
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Shick, l EE. 1985. Psychopathology among cocaine abusers - precision in diagnosis . In: Brink, C.L (Ed.) Cocaine: A Symposium: Sponsored by Wisconsin Institute on Drug Abuse and NIDA. Madison : Wisconsin Institute on Drug Abuse. Smith, D.E. 1986 . Cocaine-alcohol abuse: Epidemiologic, diagnostic and treatment considerations. Journal ofPsychoactive Drugs Vo!' 18(2) : 117-129. Spitz, H.I. & Rosecan, I .S. 1987. Overview of cocaine abuse treatment, In: Spitz, H.I. & Rosecan, I.S. (Eds.) Cocaine Abuse: New Directions in Treatment and Research. New York : Brunner-Maze!. Unsigned. 1990 . U.S. cocaine epidemic may have crested. Milwauke« Journal February II.
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Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
Clinical Diagnostic Considerations on Cocaine Abuse a
George B. Palermo & Mark T. Palermo
a
a
Medical College of Wisconsin , Milwaukee , Wisconsin Published online: 20 Jan 2012.
To cite this article: George B. Palermo & Mark T. Palermo (1990) Clinical Diagnostic Considerations on Cocaine Abuse, Journal of Psychoactive Drugs, 22:3, 313-318, DOI: 10.1080/02791072.1990.10472554 To link to this article: http://dx.doi.org/10.1080/02791072.1990.10472554
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Clinical Diagnostic Considerations on Cocaine Abuse
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George B. Palermo, M.D. * & Mark T. Palermo, M.D. ** Abstract - Following a review of the resear ch literature on the psychophysiological effects of cocaine, a study is described of a group of 120 cocaine addicts. Of the 120 patients, 10 (8.33%) exhibited fleeting, unformed, organic delusions and hallucinations . Case reports of the 10 cases are presented. The quality of the adverse subjective effects of cocaine is emphasized, and the differential diagnosis between Cocaine Delusional Disorder and Paranoid Schizophrenia is discussed. Guidelines for a more accurate differential diagnosis are prov ided. Keywords - cocaine abuse, cocaine delusional disorder, differential diagnosis, paranoid schizophrenia
Modem psychopharmacology may have begun with Freud's use of cocaine (Barchas et al. 1977). In 1884, Freud wrote (Jones 1953), "In my last severe depression, I took cocaine again and a small dose lifted me to the heights in a wonderful fashion I take very small doses of it regularly against depression with the most brilliant success." The few unfortunate experiences that he later encountered with cocaine may have contributed to the long-standing prejudice of the psychoanalytic group against psychopharmacology. Most of the research studies and clinical observations support the idea that the use of cocaine, usually by snorting , smoking or injecting, is followed by a progression of clinical syndromes: euphoria and hyperactivity, depres sion or dysphoria, paranoid reaction, and eventually psychosis. It is further accepted that the dosage and the chronic use of the drug are the primary factors for the development of the above manifestations (Post 1975). Genetic or premorbid psychopathology are important cofactors . Kindling (i.e., arousal phenomenon) facilitated by cocaine, as well as by amphetamines, has been proposed and researched extensively and magisterially by Post and Kopanda (1976). It is at the level of the limbic system-
a system of subcortical structures, including the amygdala, the hippocampus, and septal regions - that kindling originates. These anatomical structures are not only involved in the limbic ictus (also known as episodic discontrol) but also in transient behavior of a confused type. Continuous or intermittent stimulation of the amygdala in laboratory animals produces either rapid neuronal exhaustion or a kindling effect (Monroe 1982). The physiology of the limbic system can be altered not only by electrical and chemical stimulation but also by intrapsychic distress caused by the memory of adverse experiences; stress could be at the basis of the flashbacks reported by many former stimulant addicts. Episodic neurophysiological dysfunction of the limbic system, generally of short duration, may also be involved in schizophrenic reactions. Cocaine is a potent psychomotor stimulant in humans and generates behavior characterized by meticulous and repetitious arrangement of objects. According to Post (1975), "The user, paranoid, has a clear sensorium and is not con fused or disoriented. . .. Stereotype, compulsive behavior . . . can develop.... Addicts ... repetitively pursue the same task ... endlessly absorbed by minutiae." Cocaine affects neurotransmitters by blocking the synaptic reuptake of norepinephrine and dopamine, while its action on serotonin neurons is largely inhibitory. It is a potent inhibitor of monoamine reuptake at the synapse, but without any significant antidepressant activity (Barchas et al. 1977) . Reverse tolerance, potentiating the effect of catecholamines at the synapse, is produced by repetitious administration of even small doses of cocaine (Dackis & Gold 1988).
• Associate Professor of Clinical Psychiatry, Medical College of Wisconsin, Milwaukee, Wiscons in; Senior Psychia trist, Milwaukee County Mental Health Complex and DePaul Drug and Alcohol Rehabilitation Hospital, Milwaukee, Wisconsin . • · Psychiatty Resident, Medical College of Wisconsin, Milwaukee, Wisconsin . Please address reprint requests to George B. Palermo, M.D., 925 East Wells, No. 316, Milwaukee, Wisconsin 53202 . Journal ofPsychoactive Drugs
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is the possibility that the cocaine market is moving into suburban and rural areas of the United States (Backer 1987). A decline in the use of cocaine among high-school seniors and young adults was reported for 1987 (Unsigned 1988).
Resnick and Resnick (1984) and Post (1975) stated that cocaine may produce a variety of psychiatric syndromes. At times, cocaine-induced paranoia and hallucinations may lead to violent behavior, both homicidal or suicidal. Typically, shortly after using cocaine, the user suddenly becomes paranoid. Hyperexcitability and bizarre behavior are often present. In a study reported by Spitz and Rosecan (1987), 57% of the users experienced psychiatric symptoms marked by irritability, socially disruptive behavior, omnipotent feelings , suspiciousness, and hallucinations. Studies by Climent and Aragon (1984), Jeri (1984), and Washton and Tatarsky (1984) showed that cocaine abusers developed symptoms of irritability, paranoid feelings, hostility, hallucinations, and suicidal ideation. Post and Kopanda (1976) stated that "when cocaine is abused chronically, paranoid psychosis ... can result. After acute intravenous cocaine administration the development of a paranoid psychotic state (referred to by users as the bull horrors because of the intense fear of police) can occur. ... After chronic cocaine administration delusions of persecution may be vague .... Suspiciousness normally follows long term usc. " Cocaine addiction also generates compulsive behavior. Laboratory animals prefer the ingestion of cocaine to food, water, sleep or sex, and continue to do so in the face of aversive punishment and debilitation (pollack, Brotman & Rosenbaum 1989). Furthermore, cocaine remains rewarding even when administered at toxic levels (Fisher, Raskin & Uhlenhuth 1987). An experimental study by Sherer (1988) showed that "as the cocaine infusion progressed, increasing focused suspicious behavior was evident to the point of overt paranoia . Psychiatric symptoms usually dissipated within hours." In a study by Erickson and colleagues (1987), 23% of the participants reported feelings of suspiciousness. Cocaine usc increased markedly between 1974 and 1985 (pollack, Brotman & Rosenbaum 1989). In 1974, 5.4 million Americans admitted to having tried cocaine at least once; by 1985,22 million had tried it. The decreased price and increased availability of the drug, especially in the form of free-base cocaine (crack), has made it accessible to people of all ages, races, and socioeconomic classes. There were 190 cocaine-related deaths in 1981; by 1984 that figure had risen to 578. In that year, NIDA declared cocaine the drug of greatest concern (pollin 1984). A substantial increase in cocaine psychosis has also been seen at the Haight Ashbury Free Clinics, as a consequence of the increasing use of free-base cocaine (Smith 1986). A recent NIDA survey on the cocaine epidemic in the United States showed no significant increase in cocaine usc during 1989 in New York, Philadelphia, New Orleans, and Washington, D.C. (Unsigned 1990). However, there Journal of Psychoactive Drugs
CASE STUDIES The present authors extensively reviewed the literature regarding cocaine paranoid reaction. Moreover, DSM-III-R (p. 143) currently describes the syndrome Cocaine Delusional Disorder as an Organic Delusional Syndrome appearing shortly after the use of cocaine. It states that the syndrome develops shortly after the use of cocaine and that persecutory delusions arc the predominant clinical feature lasting for a week or longer, but occasionally for over a year. No detailed description of the quality of the delusions and hallucinations experienced by the paranoid cocaine addict was found either in the literature or in DSM-II1-R. This lack of information has prompted further investigation of these symptoms by the present authors in the hope of finding a consistent basis that would enable clinicians to better differentiate the cocaine paranoid reaction from paranoid schizophrenia. In the present study, the diagnostic category Cocaine Paranoid Reaction is interchangeable with Cocaine Delusional Disorder in DSM-III-R . A group of 120 patients, who had used cocaine for periods ranging from one to 12 years, was examined at the DePaul Drug and Alcohol Rehabilitation Hospital in Milwaukee and at the Milwaukee County Mental Health Complex Forensic Unit. Of the 120 patients, 10 (8.33%) exhibited persecutory ideas in addition to the vague suspiciousness that is usually present in cocaine addicts. Previously, five of these 10 patients had been diagnosed by private practitioners or by clinicians at local community psychiatric hospitals as suffering from paranoid schizophrenia. During the first 72 hours, the treatment of the 10 patients included in the study was limited to milieusupportive therapy, and no psychotropic medication was used during the first week. Four case examples are provided below. Case 1 T.e. is a 22-year-old Black male who came to the hospital asking for help because of auditory hallucinations and feelings of persecution. Two years earlier, in a psychiatric hospital in Milwaukee, he had been diagnosed as suffering from paranoid schizophrenia. His ideas of persecution were extremely vague: "People are against me. They are trying to do something against me. I don't know who they are ." The auditory hallucinations consisted of a "whispering voice." Psychomotor agitation was present. His sensorium was clear and he made good eye contact. 314
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He had a six-year history of addiction to snorting and smoking cocaine. A diagnosis of paranoid reaction due to cocaine was made. After 36 hours, the patient's symptomatology abated.
with which they were threatening him. The type of hallucinations was expressed as follows: "I hear a voice in my head talking to me." He showed good eye contact and some restlessness. He described the usual Magnan formication. A diagnosis of paranoid reaction due to cocaine was made. He was free from his delusions and hallucinations 36 hours later.
Case 2 W.T. is a 24-year-old Black male who came to the hospital because he could no longer tolerate his four-year cocaine addiction. A year earlier he had been diagnosed, in another mental health care institution in Milwaukee, as a paranoid schizophrenic with manic features. He was talkative, slightly exuberant, and showed good eye contact. His paranoid ideation consisted of "people and the police are after me." His auditory hallucinations were described as "whispering sounds." His sensorium was clear. He expressed his wish to get help. A diagnosis of Paranoid Cocaine Reaction was made. Two days later he was free from his paranoid ideation.
DIFFERENTIAL DIAGNOSIS The vagueness, concreteness, and meagerness of the so-called delusions and hallucinations exhibited by the cocaine addict suffering from a delusional disorder make them akin to the secondary delusions described by Jaspers (1963). The delusional ideas could easily be understood as elaborations of affectively important events in the patients' present lives. The patients in the present study had delusions that were concrete, unformed, vague, and persecutory in quality: "People are against me. They are trying to do something to me. I don't know who they are." Paranoid ideation in these patients usually disappeared within 24 to 48 hours. Shick (1985) has reported that "suicidal preoccupation and paranoid ideation among cocaine abusers tended to disappear more rapidly than [was] originally envisioned, usually within the first 24 hours of admission." The patients in the present study felt pervasive suspiciousness punctuated by distressing paranoid delusions. They believed that others were "spying on me" or "out to get me." The patients who suffered from Cocaine Paranoid Reaction always exhibited a certain restlessness and psychomotor agitation. The patients' vague paranoid ideation, restless hypervigilant behavior, and purposeless agitation are quite in contrast with the classic picture of paranoid schizophrenia. For example, in his classic work Textbook ofPsychiatry, Bleuler (1934) stated that "one speaks of a defect in the emotional rapport, which is an important sign of schizophrenia. One feels emotionalIy more in touch with an idiot who does not utter a word than with a schizophrenic who can still converse well, intellectually, but who is inwardly unapproachable." Again, referring to schizophrenia, he stated that "there is a loss of affectivity or indifference." However, the paranoid behavior of cocaine addicts shows a certain obsessive searching for the fantasized persecutors. As the wife of a patient told one of the authors (G. Palermo), "For hours my husband, while under the effect of cocaine, had the shades in our bedroom windows pulled down and was peeking out of the window in an obsessive search for unidentified people supposedly after him. At times he spoke of the police and neighbors." The visual hallucinations described by the patients in the present study group appeared as gross misinterpretations of reality, with abstract images and alterations of color, size, and shape, which are typical of an organic ori-
Case 3 J.S., a 26-year-old White female, was examined in the Milwaukee County Jail by one of the authors (G. Palermo) on the request of the jail's nursing office. She was agitated, her affect was minimally depressed, she was suspicious, and had paranoid ideation. Her medical history revealed that two years earlier a diagnosis of schizo-affective reaction with paranoid ideation had been made by a local psychiatrist in private practice. She showed normal prosody and a sad, depressed look . She exhibited psychomotor agitation but had good eye contact. During the previous four years, she had been using half an ounce of cocaine daily by snorting, smoking, and intravenous injection. Occasional alcohol abuse also occurred. She experienced paranoid ideation, claiming that people in general and police undercover agents were watching her. She also had unformed auditory hallucinations in which she heard unintelligible words. She was asking for help. A diagnosis of Paranoid Cocaine Reaction was made. Forty hours later she was free from paranoid ideation and auditory haIlucinations. Case 4 J.e. is a 29-year-old Black male who, while being examined, stated that "I am tired of the way I am living. 1 can't keep no job, no money, and 1 don't know what is going on ." Three years earlier he had been diagnosed at a local psychiatric hospital as suffering from schizophrenia; Haldol and Cogentin were prescribed during his hospitalization. His medical history also revealed an addiction to cocaine, with daily use ("As often as 1can get money.") for the previous six years. His paranoid ideation consisted of "people are against me and are trying to do something to me." He was unable to identify the people. He was fearful of them, but he was unable to state the type of harm Journal of Psychoactive Drugs
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"psychotic symptoms and depression are usually brief and remit following prolonged sleep, but may require observation and suicide prevention.... Counseling or psychotherapy are usually employed." In addition, Estroff (1987) has pointed out that " the cocaine addict has sufficient reality testing left to realize that his perceptions are not correct, despite the experience of paranoid thoughts and auditory hallucinations." The reality testing of the patients in the present study was fairly good, while the reality testing of paranoid schizophrenics is quite poor. Estroff also stated that "knowing that their symptoms are not real they have enough self-control not to act on their psychotic symptoms, but this docs not keep them from constantly checking their environment. They remain hypervigilant, often staring out of a window for hours, watching for the police, for the F.B.I., believing that they are 'out to get me."' Gawin (1986) reported two cases of paranoid reaction due to cocaine. Both of the addicts' delusions centered around their possible persecution by either federal drug enforcement agents or imaginary drug dealers. These patients recovered rapidly - within one day of ending a cocaine binge. In addition to a rapid recovery period, the present authors' clinical experience has shown that addicts who have recovered from a previous Delusional Disorder due to cocaine usually have a clear recollection of their paranoid ideation and hallucinatory experiences. Finally, it should not be forgotten that cocaine abusers may be self-medicating a psychiatric disorder, and a dual diagnosis may be indicated .
gin according to DSM-Ill-R. In these cases.the auditory hallucinations were mostly poorly defined noises, music, whispering or indistinct voices: tinnitus and buzzing were heard at times, and the voices had an obsessive quality. The schizophrenic splitting between thought and affect described by Bleuler was never observed in the patients in the present study group. When relating the pseudoparanoid ideas, the patients did not show the flatness of affect or emotional detachment that Bleuler portrayed. Their affect was at unison with the content of their thinking. Insight (i.e., the realization of being in an abnormal condition), which is absent in the schizophrenic reaction except in some initial phases, was present in the patients in the present study. The age of the patients should be taken into consideration. As Arieti (I 959) stated in his Handbook on Psychiatry, "Onset of paranoid schizophrenia usually occurs a lillie later in life than other types. It is more common in the fourth and fifth decades." On the contrary, the patients in the present study were in their twenties and thirties. In Modern Clinical Psychiatry, Noyes and Kolb (I958) stated that paranoid schizophrenia "occurs most frequently after thirty years of age." In support of a later onset of Paranoid Schizophrenia, as opposed to that of Cocaine Delusional Reaction , DSM-lll-R (p. 197) clearly indicates that "onset of paranoid schizophrenia tends to be later in life that the other types." In addition, DSM-lll-R states that "occupational functioning and capacity for independent living is considerably better than other types of schizophrenia." Instead, the paticnts in the present study were unable to function and they had lost their capacity for independent living. Their hyperactivity, ritualistic stereotyped behavior, paranoid suspiciousness and delusional ideas impeded them from properly and gainfully involving themselves in the business oflife. Usually, paranoid schizophrenics are not only irritable, resentful, discontented , and angrily suspicious, but they show a surly aversion to being interviewed. The cocaine-paranoid patients, on the contrary, showed an intense desire for communication and help. Their premorbid personality was not that of a schizoid, but that of a sociopathic personality that has been abusing drugs in excess, especially cocaine, for many years. However, Weiss and Mirin (1987) reported that 90% of39 hospitalized chronic cocaine abusers met DSM-lIl-R criteria for Personality Disorder, Borderline or Narcissistic type, and only three percent met criteria for Antisocial Personality. The recovery period of the cocaine addict suffering from a delusional persecutory disorder is also remarkably short, unlike the paranoid schizophrenic. He or she usually recovers from the delusions promptly and without medication. At times, within a period as short as 24 hours to a maximum of five days, his or her pseudoparanoid ideation completely disappears . Wang (1987) stated that Journal of Psy choactive Drugs
CONCLUSIONS AND RECOMMENDATIONS
Delusional persecutory disorder due to cocaine is a rare, self-limited entity. Its disappearance is quite sudden and dramatic, usually after a 24-48 hour cocaine-free period. In order not to throw the cocaine addict suffering from a delusional disorder of a persecutory type into the large cauldron of paranoid schizophrenia, the following recommendations arc made: I. A period of observation (maximum 48 hours), possibly without prescribing psychotropic medication, would allow the patient to return to his or her normal selfbecausc of the very short half-life of cocaine in the blood. 2. A thorough history should be taken and a physical examination should be performed. The patient should be specifically questioned regarding the use of cocaine (i.c., for how long, how much, and how often). A urine test for cocaine should be a routine procedure. The clinician should gather specific information as to when the symptoms began and their relationship to possible alcohol or other drug intake. The clinician should also inquire about masturbatory rituals, coke bugs, paranoia, and vi316
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6.
7.
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a clearer state of mind, free from delusions and hallucinations. 10.A reassessment of the patient's behavior as well as mental andphysical status at the end of24 hours and for three consecutive days is mandatory. 11. A straitjacket of psychotropic medication should be avoided because it would only complicate the differential diagnosis. By following these recommendations, the differential diagnosis between paranoid schizophrenia and a delusional syndrome due to cocaine abuse may be facilitated, and the erroneous labeling of the cocaine addict with paranoid reaction as paranoid schizophrenic would not ensue. Misdiagnosing a patient with a Cocaine Delusional Reaction as schizophrenic-paranoid type could have present and future consequences for his or her therapy and rehabilitation. Clinicians should always remember the Hippocratic dictums, "Observation win always lead to proper diagnosis" and "Nature has its own healing power." However, a very cautious, supportive pharmacological intervention may, at times, be necessary. Counseling and milieu therapy are of paramount importance. Clinical observation of patients over a long period of time and numerous scientific studies have proven cocaine to be utterly disturbing to the human mind and profoundly disruptive to society. As Cohen (1985) aptly stated, "Cocaine is . .. an entrapping agent that promises happiness and, in the end, offers nothing but disaster."
sual hallucinations as wel1 as look for the presence of mydriasis (i.e ., cocaine-induced enhancement of norepinephrine that potentiates the action of the sympathetic fibers that innervate the radial muscle of the iris). An inquiry should be made regarding any psychiatric illness preceding the addiction. Friends and relatives of the patient should be interviewed, if possible. The paranoid patient should be asked to accurately describe the quality of delusions or hal1ucinations from which he or she may suffer, in order to elicit the presence of unformed pseudodelusions or organic auditory hal1ucinationstypical of cocaine intoxication. The affectivity of the patient should be given due attention, as there is no flatness of affect in the cocaine paranoid patient. The presence of psychomotor agitation in a delusional patient and his or her insistent search for communication and help should alert the clinician that a toxic reaction to cocaine is present rather than paranoid schizophrenia. An important differentiating factor is the age of the patient: the patient suffering from a delusional persecutory disorder due to cocaine is usually much younger than the paranoid schizophrenic. The recovery time should be monitored. Indeed, a good night's sleep without cocaine may be enough to return the cocaine paranoid patient to
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Diagnostic Considerations on Cocaine Abuse Unsigned. 1988. Government campaign to halt drug abuse beginning to show some success. Psychiatric News Vol. 23 : 17. Wang, R.I . 1987. Practical Drug Therapy. Milwaukee: Meadstream Press. Washton, A.M. & Tatarsky, A. 1984. Adverse effects of cocaine abuse. In: Harris, LS. (Ed.) Problems ofDrug Dependence. 1983 . NIDA Research Monograph 49. Rockville, Maryland: NIDA. Weiss, R.D. & Mirin, S.W. 1987. Cocaine . Washington, D.C. : American Psychiatric Press.
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Shick, l EE. 1985. Psychopathology among cocaine abusers - precision in diagnosis . In: Brink, C.L (Ed.) Cocaine: A Symposium: Sponsored by Wisconsin Institute on Drug Abuse and NIDA. Madison : Wisconsin Institute on Drug Abuse. Smith, D.E. 1986 . Cocaine-alcohol abuse: Epidemiologic, diagnostic and treatment considerations. Journal ofPsychoactive Drugs Vo!' 18(2) : 117-129. Spitz, H.I. & Rosecan, I .S. 1987. Overview of cocaine abuse treatment, In: Spitz, H.I. & Rosecan, I.S. (Eds.) Cocaine Abuse: New Directions in Treatment and Research. New York : Brunner-Maze!. Unsigned. 1990 . U.S. cocaine epidemic may have crested. Milwauke« Journal February II.
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