Home ] Up ]

 

 
 
 
 
Home  |  Specialties  |  CME  |  PDA  |  Contributor Recruitment  |  Patient Education
  Articles Images CME Patient Education Advanced Search Link to this site
Back to: eMedicine Specialties > Medicine, Ob/Gyn, Psychiatry, and Surgery > Psychiatry

Inhalant-Related Psychiatric Disorders

Last Updated: June 19, 2002
Rate this Article
Email to a Colleague
Synonyms and related keywords: huffing, sniffing, bagging, volatile substance abuse, substance abuse, drug abuse, drug-induced psychosis, inhalant abuse, inhalant dependence, inhalant intoxication, substance intoxication delirium, substance-induced anxiety disorder, inhalant-related disorder NOS, inhalant-related disorder not otherwise specified, substance-induced psychotic disorder, depression, general anxiety disorder, sudden sniffing death syndrome

  AUTHOR INFORMATION Section 1 of 10    Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Author: Guy E Brannon, MD, Director of Adult Psychiatry Service, Brentwood Behavior Health Company; Assistant Clinical Professor, Department of Psychiatry, Louisiana State University at Shreveport

Coauthor(s): Jeanie McGee Gary, BS, Editorial Manager, Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport

Guy E Brannon, MD, is a member of the following medical societies: American College of Clinical Pharmacology, American Medical Association, American Medical Women's Association, American Psychiatric Association, American Society of Addiction Medicine, Louisiana State Medical Society, and Southern Medical Association

Editor(s): Barry I Liskow, MD, Vice Chairman, Program Director, Professor, Department of Psychiatry, University of Kansas Medical School; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Iqbal Ahmed, MD, Program Director, General and Geriatric Psychiatry Residency Programs, Vice Chair for Education, Professor, Department of Psychiatry, John a Burns School of Medicine, University of Hawaii; Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry, Assistant Professor, Department of Medicine, Froedtert Hospital, Medical College of Wisconsin; and Stephen Soreff, MD, Director of Quality Improvement, President of Education Initiatives, HMA Behavioral Health, Inc
  INTRODUCTION Section 2 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Background: Inhalant-related psychiatric disorders are a heterogenous group of illnesses that are caused by the abuse of solvents, glues, paint, fuels, or other volatile substances, excluding anesthetic gases, which are not included in the category.

Although huffing, as it is referred to commonly, has existed since ancient times, it has regained popularity in recent years. The resurgence of this newfound phenomenon is believed to be due to a number of variables, which have made this potentially fatal activity popular among many young people today.

Because most of the products used in huffing are legal household products, they are easily accessible and are relatively inexpensive to obtain. Most recent reports state that nearly 1000 such products are available to huffers every day. Some of the most common products used for inhaling are spray paint (containing butane, lead, or propane), permanent markers, correction fluid (eg, Liquid Paper, Wite-Out), glue (containing toluene or ethyl acetate), lighter fluid (containing butane or isopropane), hairspray (containing butane or propane), propane, gasoline (containing lead), and kerosene. Due to the increase in awareness of the potential dangers caused by sniffing or inhaling, laws have been established prohibiting the sale of certain products to minors; however, enforcing these laws is difficult.

Generally, adolescents practice huffing; however, younger children and young adults also engage in this potentially fatal act. Huffing involves placing the volatile substance (most commonly some type of chemical, eg, butane found in spray paint, acetone found in nail polish remover) on a rag or in a closed container (eg, soda can, plastic bag), placing the rag over the nose and mouth, and breathing deeply to cause mood-altering effects.

The effects experienced by persons who use inhalants vary from excitement and euphoria to confusion, disorientation, and hallucinations. Most persons who abuse inhalants experience a lessening of inhibitions, loss of coordination, and muscle relaxation. Most who abuse inhalants continue to sniff to produce the feeling of euphoria. The effects last from minutes to hours, depending on the chemical being inhaled; then, the person experiences a hangover.

The inhalation of these substances can cause permanent organ damage and death. Huffing is a problem not only in the United States, but also abroad, and accounts for a large portion of emergency department visits. Diagnosis of inhalant-related psychiatric disorders is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) or International Classification of Diseases, 10th Revision criteria.

Although studies have shown that inhalant abuse has been difficult to diagnose, treatment efforts for inhalant-related psychiatric disorders may be promising. Treatment consists of psychotherapy (eg, 12-step programs similar to Alcoholics Anonymous, cognitive behavior therapy, rational-emotive therapy) and pharmacotherapy. Early intervention may play a key role because engagement in this activity may lead to the use of other drugs.

Pathophysiology: Inhalants are CNS depressants (similar to alcohol) and are thought to influence GABA, although the exact mechanism has yet to be determined. No evidence associates inhalants with the opiate system; N-methyl-D-aspartate may play a role.

Medical effects

Psychiatric effects

The psychiatric effects of inhalant abuse include impaired judgment, confusion, fright, hyperactivity, anxiety, acute psychosis, increased violence and aggressive behavior, depression, organic brain syndrome (ie, coarse tremor, staggering gait, speech problems, thought disorder), abuse, tolerance and dependence, hallucinations, decreased intelligence quotient, intoxication, mood disorder, dementia, and withdrawal. Inhalant abuse also affects social, educational, and economic status. In addition, those who abuse inhalants are more likely to be involved in accidents.

Frequency:

  • In the US: Of the population, 5% have tried huffing once and 1% are current users. According to statistics gathered by the National Inhalant Prevention Coalition, ". . . by the time a student reaches the eighth grade, 1 in 5 will have used inhalants." Inhalants account for 1% of substance-induced death.
  • Internationally: Incidents occur worldwide, but determining exact numbers is difficult.

Mortality/Morbidity: Inhalants work quickly by passing through the nasal cavity and entering the lungs, bloodstream, and the brain, all in a matter of seconds. The chemical vapors of the inhalants are dissolved into the fatty tissues of the brain. The results of inhalant abuse affect virtually every organ and function of the body, including the brain, heart, lungs, kidneys, muscle, bone marrow, and peripheral and central nervous systems, to name a few. Those who abuse inhalants for the long-term may become disabled permanently, losing their ability to walk, talk, and think. The possible damage depends on the chemical used, the frequency with which it is used, and the amount used.

Race: Persons who abuse inhalants predominantly are white; however, studies have found minority involvement in subcultures of American and Canadian Indians and in Hispanic persons with low income status. Inhalant use is more common in rural and suburban areas than in urban areas.

Sex: Although long-term inhalant use is more common in males than in females, experimental use is equally common in males and females.

Age: Experimental use of inhalants normally occurs in late childhood and early adolescence (age 9-13 y). Long-term use appears during early and late adolescence (age 12-17 y). Inhalants commonly are the first substance used before the onset of substance (eg, tobacco, alcohol, marijuana, cocaine) abuse occurs. Inhalant abuse among younger children and adults is less frequent, although it does occur
  CLINICAL Section 3 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

History: Those who abuse inhalants commonly share characteristics that may help identify them as users. While taking the patient's history, determine their diagnosis based on the DSM-IV criteria for inhalant abuse, inhalant dependence, inhalant intoxication, substance intoxication delirium, substance-induced persistent dementia, substance-induced psychotic disorder, substance-induced mood disorder, substance-induced anxiety disorder, and inhalant-related disorder not otherwise specified (NOS). Pay close attention to the signs and symptoms that are commonly associated with persons who abuse inhalants (see below). Inquire about other drugs of abuse and a family history of drug and alcohol abuse or addiction.

  • Characteristics of persons who abuse inhalants

    • Delinquency

    • Theft and burglary

    • Poor school attendance

    • Frequent suspension and expulsion from school

    • Social outcasts

    • Impoverished families or middle-to-upper income status

    • Lack of parental control or guidance

    • Attention deficit

    • Poor academic performance

    • Antisocial personality

    • Depressive disorders

    • Emotional problems (specifically anxiety, depression, and anger)

    • Low self-esteem

    • Peer pressure with drug influence
  • Criteria for inhalant abuse, adapted from the DSM-IV

    • A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

      • Recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home

      • Recurrent substance use in situations in which it is physically hazardous

      • Recurrent substance-related legal problems

      • Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

    • Symptoms never meeting criteria for substance dependence for this class of substance
  • Criteria for inhalant dependence, adapted from the DSM-IV: A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 3 (or more) of the following, occurring at any time in the same 12-month period:

    • Tolerance

      • A need for markedly increased amounts of the substance to achieve intoxication or desired effects

      • Markedly diminished effects with continued use of the same amount of the substance
    • Withdrawal

      • Characteristic withdrawal syndrome for the substance

      • Same (or a closely related) substance taken to relieve or avoid withdrawal symptoms
    • Substance often taken in larger amounts or over longer periods than was intended

    • A persistent desire or unsuccessful effort to cut down or control substance use

    • Significant time is spent in activities necessary to obtain the substance or recover from its effects

    • Important social, occupational, or recreational activities are given up or reduced because of the substance use

    • Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance
  • Criteria for inhalant intoxication, adapted from the DSM-IV

    • Recent intentional use or short-term high-dose exposure to volatile inhalants

    • Clinically maladaptive behavioral or psychological changes that developed during or shortly after use of or exposure to volatile inhalants

    • Two (or more) of the following signs developing during or shortly after inhalant use or exposure:

      • Dizziness

      • Nystagmus

      • Incoordination

      • Slurred speech

      • Unsteady gait

      • Lethargy

      • Depressed reflexes

      • Psychomotor retardation

      • Tremor

      • Generalized muscle weakness

      • Blurred vision or diplopia

      • Stupor or coma

      • Euphoria

    • Symptoms not due to a general medical condition and not better accounted for by another mental disorder
  • Criteria for substance intoxication delirium, adapted from the DSM-IV

    • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention

    • A change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia

    • Disturbance occurs over a short period of time and tends to fluctuate during the course of the day

    • Evidence from the history, physical examination, or laboratory findings of either of the following:

      • Symptoms of (1) disturbance of consciousness with reduced ability to focus, sustain, or shift attention or (2) a change in cognition or the development of perceptual disturbance that is not accounted for by a preexisting, established, or evolving dementia that developed during substance intoxication

      • Medication use etiologically related to the disturbance
  • Criteria for substance-induced persistent dementia, adapted from the DSM-IV

    • Development of multiple cognitive deficits manifested by both (1) memory impairment and (2) one (or more) of the following cognitive disturbances:

      • Aphasia

      • Apraxia

      • Agnosia

      • Disturbance in executive functioning

    • Cognitive deficit in (1) memory impairment and (2) aphasia, apraxia, agnosia, or disturbance in executive functioning each cause significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning

    • Deficients do not occur exclusively during the course of a delirium and persist beyond the usual duration of substance intoxication or withdrawal

    • Evidence from history, physical examination, or laboratory findings that deficits are etiologically related to the persistent effects of substance use
  • Criteria for substance-induced psychotic disorder, adapted from the DSM-IV

    • Prominent hallucinations or delusion

    • Evidence from history, physical examination, or laboratory findings of either of the following:

      • Symptoms of prominent hallucinations or delusion developing during or within 1 month of substance intoxication or withdrawal

      • Medication use etiologically related to the disturbance

    • Disturbance not better accounted for by a psychotic disorder that is not substance induced

    • Disturbance does not occur exclusively during the course of a delirium
  • Criteria for substance-induced mood disorder, adapted from the DSM-IV

    • Prominent and persistent disturbance in mood predominates in the clinical picture and is characterized by either (or both) of the following:

      • Depressed mood or markedly diminished interest or pleasure in all, or almost all, activities

      • Elevated, expansive, or irritable mood

    • Evidence from history, physical examination, or laboratory findings of substance intoxication or withdrawal and the symptoms of (1) depressed mood or markedly diminished interest or pleasure activities and (2) elevated, expansive, or irritable mood developing during or within 1 month of substance intoxication or withdrawal

    • Disturbance not better accounted for by mood disorder that is not substance induced

    • Disturbance does not occur exclusively during the course of a delirium

    • Disturbance causes clinically significant distress or impairment in social, occupational, or other important area of functioning
  • Criteria for substance-induced anxiety disorder, adapted from the DSM-IV

    • Prominent anxiety, panic attacks, obsession, or compulsion predominating in the clinical picture

    • Evidence from history, physical examination, or laboratory findings of either of the following:

      • Symptoms of prominent anxiety, panic attacks, obsession, or compulsion developing during or within 1 month of substance intoxication or withdrawal

      • Medication use etiologically related to the disturbance
    • Disturbance not better accounted for by an anxiety disorder that is not substance induced
    • Disturbance not occurring exclusively during the course of a delirium
    • Disturbance causes clinically significant distress or impairment in social, occupational, or other important area of functioning
  • Criteria for inhalant-related disorder NOS, adapted from the DSM-IV: The inhalant-related disorder NOS category is for disorders associated with the use of inhalants that are not classified as inhalant dependence, inhalant abuse, inhalant intoxication, inhalant intoxication delirium, inhalant-induced persistent dementia, inhalant-induced psychotic disorder, inhalant-induced mood disorder, or inhalant-induced anxiety disorder.

Physical:

  • Perform a detailed neurological evaluation to look for the following:
    • Apathy
    • Impaired judgment
    • Impulsiveness
    • Aggressive behavior
    • Anorexia
    • Nystagmus
    • Depressed reflexes
    • Altered levels of consciousness
  • In addition, be aware of the signs and symptoms of inhalant abuse when performing the physical examination; for example, look for the following:
    • Amnesia
    • Rashes (particularly around the hand, nose, and mouth)
    • Unusual breath odors (eg, chemical smells)
    • Red or irritated eyes, throat, lungs, and nose

Causes: Much speculation exists on the cause of inhalant abuse. Its popularity appears to be based on the fact that the substances are easily accessible to young people. The products used are fairly easy to hide, fairly inexpensive, easily attainable, and, for the most part, are legal. Therefore, inhalants are readily becoming the drugs of choice. Many adolescents are becoming interested in the instant gratification huffing offers, while others engage in huffing merely because their friends are doing it. However, a subgroup of young people still exists who abuse inhalants because they have seen their parents or older siblings abuse illegal drugs, and these young people have decided that huffing is the activity they choose to begin their drug use and addiction.
  DIFFERENTIALS Section 4 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Anxiety Disorders
Delirium
Depression
Stimulants


Other Problems to be Considered:

Because substance-induced psychiatric disorders resemble the primary mental disorders (ie, major depression, generalized anxiety disorder), these should be considered in the differential diagnosis.

Other disorders to consider include the following:
Conduct disorder
Antisocial personality disorder
Alcohol abuse and dependence
Cannabis abuse and dependence
Temporal lobe epilepsy
Psychosis
Polysubstance dependence

Quick Find
Author Information
Introduction
Clinical
Differentials
Workup
Treatment
Medication
Follow-up
Miscellaneous
Bibliography

Click for related images.

Related Articles
Anxiety Disorders

Delirium

Depression

Stimulants



  WORKUP Section 5 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Lab Studies:

  • Sequential multiple analysis
    • Electrolyte (eg, sodium, potassium, chloride) levels
    • Liver function tests
    • BUN determination
    • Creatinine level
    • Cholesterol level
    • Anion gap measurement
  • Complete blood cell count with differential and platelets
  • Urinalysis
  • Urine drug screen
  • Rapid plasma reagin testing
  • Thyroid-stimulating hormone testing
  • Thyroid function tests
  • Urine pregnancy tests
  • Creatine kinase, if not included in sequential multiple analysis
  • Twenty-four–hour urine test
  • Heavy metal screening test
  • HIV-antigen test

Imaging Studies:

  • Perform a chest radiograph.
  • Perform a CT scan to help identify brain atrophy. Include cerebral and cerebellar regions and the brainstem.
  • Perform an MRI to help identify brain atrophy and white matter disease or leukoencephalopathy.
  • Perform a positron emission tomography (PET) scan to help identify decreases in cerebral blood flow.
  • Order a CT scan and electroencephalogram (EEG) if neurological symptoms are present (eg, hearing loss, headaches, cerebellar signs, paresis, motor impairment, parkinsonism, encephalopathy).
  • Perform an EEG to help identify seizure activity, specifically temporal lobe epilepsy.
  • If PET scanning is not available, perform single-photon emission computed tomography scanning to help identify nonhomogenous uptake of radiopharmaceuticals, which may indicate hypoperfusion and hyperperfusion foci.

Other Tests:

  • Electrocardiogram (may be necessary)
  • Wechsler Adult Intelligence Scale
  • Wide Range Achievement Test
  • Trail-Making Test

Procedures:

  • Liver or kidney biopsy, if indicated
Histologic Findings: Findings may include evidence of heavy metal damage to specific organs, such as that caused by lead in gasoline and paint, and inflammation, rhabdomyolysis, brain atrophy, and renal tubular acidosis.

  TREATMENT Section 6 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Medical Care:

  • No controlled studies have been performed to guide the treatment of patients who abuse inhalants and have inhalant dependence. Additionally, no specific medications indicated by the pharmaceutical industry are available for detoxification from inhalants.

  • Programs that specifically treat inhalant abuse do exist; however, they are rare and difficult to find. Therefore, treatment planning most often is tailored much like that of the treatment of patients with chemical dependence, in which the first step is to detoxify the patient.
    • Patients who are addicted to inhalants experience withdrawal symptoms similar to those of any other patient addicted to drugs, including tremors, chills, sweats, cramps, nausea, and hallucinations.

    • Next, a peer system is established.

    • Once these 2 tasks are accomplished, assess the patient for physical, cognitive, and neurologic problems. If any problems are noted in these areas, they must be treated immediately. Identify any strengths the patient has and build on these strengths to increase them and to create new additional strengths for the patient. Address any other problems they may have. The goal is to get the patient back into the community with a drug-free peer network and continuing or enhanced self-support.

    • Treat any conduct problems noted.

    • Once the patient is detoxified, evaluate for other psychiatric illnesses using the DSM-IV.
  • The patient should participate in group therapy sessions, 12-step programs/chemical dependency groups, rational-emotive therapy, cognitive behavior therapy, and family therapy.

  • Discuss safe sex with the patient, including partner precautions and birth control. In addition, the family should receive education about the disorder, secure substances that could be huffed, and become familiar with local mental health laws regarding commitment policies.

  • No medications should be used unless a treatable DSM-IV diagnosis has been identified.

    • If the patient has depression independent of the inhalant abuse, treat with the antidepressant of choice.

    • If the patient has alcohol abuse coexisting with inhalant abuse, disulfiram (Antabuse) or naltrexone can be used to treat appropriate patients.

    • If the patient meets DSM-IV criteria for attention-deficit/hyperactivity disorder, a psychostimulant such as Cylert can be used to treat the patient.

    • If the patient is psychotic as a result of the inhalant abuse (inhalant-induced psychosis), the physician may use an appropriate antipsychotic such as haloperidol or Risperdal, with or without a benzodiazepine. This is the physician's choice.

    • If the patient has an inhalant-induced mood disorder, detoxification is recommended, without the use of any medications unless the depression persists for longer than 2-4 weeks after withdrawal.

    • Detoxification also is recommended for patients who are experiencing inhalant-induced anxiety; however, the use of sedatives or antianxiety medications is contraindicated because inhalant intoxication can worsen if the patient uses again.
  • If the patient cannot maintain sobriety, the physician should consider residential treatment options, which can last anywhere from 3-12 months.
  • Most persons who abuse inhalants receive most of their medical care in local emergency departments after they have either passed out or become psychotic from chemical inhalation. In the emergency department, they receive supportive care, social interventions, and appropriate medical care.

Surgical Care:

  • Patients may need liver or kidney transplantation.

Consultations:

  • Chemical dependence counselor
  • Attorney, if legal problems develop
  • Social worker
  • Family therapist
  • Peer group therapist
  • Dietitian (possibly)

Diet:

  • Consultation with a dietitian may be helpful if patients have poor nutrition (eg, liver problems, low protein).
  • If no additional medical problems are present, patients can eat a regular diet.

Activity:

  • Maintain sobriety.
  • Patients who are not a danger to themselves or others, are not gravely disabled, and are medically stable can maintain routine activities.
  MEDICATION Section 7 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

If psychosis or delirium is present, use an antipsychotic such as risperidone or haloperidol and/or an anticonvulsant such as carbamazepine. Avoid benzodiazepines because they may worsen respiratory depression.

Drug Category: Antipsychotics -- Reduce psychosis and aggressive behavior. All antipsychotics may be equally efficacious, but their adverse affect profiles are different. The atypical antipsychotics such as risperidone, olanzapine, quetiapine, and ziprasidone have an advantage in the adverse effect profile, especially in their lower risk to cause adverse extrapyramidal effects and tardive dyskinesia.
Drug Name
Haloperidol (Haldol) -- Used for the management of psychosis. Also used to treat motor and vocal tics in children and adults.
Adult Dose 0.5-5 mg PO bid; 2-5 mg IM q4-8h
Pediatric Dose 3-12 years (15-40 kg): 0.05-0.15 mg/kg/d PO
Contraindications Documented hypersensitivity; narrow-angle glaucoma; bone marrow suppression; severe cardiac or liver disease; severe hypotension; subcortical brain damage
Interactions May increase tricyclic antidepressant serum concentrations and hypotensive action of antihypertensive agents; phenobarbital or carbamazepine may decrease effects; coadministration with anticholinergics may increase intraocular pressure; encephalopathylike syndrome associated with concurrent administration of lithium
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with thyrotoxicosis also receiving antipsychotics; if IV/IM, watch for hypotension; caution in diagnosed CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; significant increase in body temperature may indicate intolerance to antipsychotics (discontinue if it occurs); elevates prolactin levels
Drug Name
Risperidone (Risperdal) -- Binds to dopamine D2 receptor with 20 times lower affinity than 5-HT2–receptor affinity. Improves negative symptoms of psychoses and reduces incidence of adverse extrapyramidal effects.
Adult Dose 0.25-6 mg/d PO qd/bid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions Coadministration with carbamazepine may decrease effects; may inhibit effects of levodopa; clozapine may increase levels
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Orthostatic hypotension, seizures, dysphagia, hyperprolactinemia, cognitive and motor impairment, priapism, and rare thrombotic thrombocytopenic purpura may occur
Drug Category: Anticonvulsants -- Usually used to treat seizures but have been used for treatment of manic-depressive symptoms and behavioral agitation. Other anticonvulsants such as valproic acid (Depakene) or divalproex sodium (Depakote) may also be as effective as carbamazepine.
Drug Name
Carbamazepine (Tegretol) -- Used to treat epilepsy and trigeminal neuralgia.
Adult Dose 200-600 mg bid; 800-1200 mg/d maintenance
Pediatric Dose <6 years: 10-20 mg/kg/d bid; <35 mg/kg/d maintenance
6-12 years: 100 mg bid; 400-800 mg/d maintenance
Contraindications Documented hypersensitivity; administration of MAOIs within last 14 d; history of liver disease and blood dyscrasias
Interactions Do not coadminister with MAOIs; cimetidine may increase toxicity, especially if taken in first 4 wk of therapy; grapefruit juice, danazol, isoniazid, cimetidine, fluoxetine, erythromycin, and phenelzine increase plasma levels; phenytoin, alprazolam, clonazepam, primidone, and phenobarbital decrease levels
Decreases levels of imipramine, phenothiazines, haloperidol, ritonavir, contraceptives, risperidone, thiothixene, corticosteroids, doxycycline, trazodone, and amitriptyline; increases plasma levels of diltiazem and verapamil; can reduce its own level by autoinduction; coadministration with clozapine further increases bone marrow toxicity and resulting agranulocytosis
Pregnancy D - Unsafe in pregnancy
Precautions Very small but significant risk of causing agranulocytosis or aplastic anemia; can cause drowsiness, dizziness, and blurred vision; caution while driving or performing other tasks requiring alertness; caution in mixed seizure disorders and cardiac, renal, liver, or hematological problems; report any indications of blood dyscrasias (eg, easy bruising, sore throats, fever, rash)
  FOLLOW-UP Section 8 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Further Inpatient Care:

Further Outpatient Care:

  • Therapy should include interventions such as a 12-step program or chemical dependency counseling, cognitive behavior therapy, or rational-emotive therapy.
  • Continued pharmacotherapy may be indicated.
  • Patients may need to join Alcoholics Anonymous.

In/Out Patient Meds:

  • Continued pharmacotherapy depends on the diagnosis and what medications were started in the hospital.

Transfer:

  • Transfer to a medical/surgical hospital may be necessary.
  • If legal problems develop, transfer to prison, jail, or a juvenile detention center may be necessary.

Deterrence/Prevention:

  • Educating those who abuse inhalants, students, teachers, educators, parents, and the community in general may help prevent further abuse.
  • Early identification of the problem may help prevent continued abuse.

Complications:

  • Social problems

  • Difficulty at work
  • Psychosis

  • Dementia
  • Anxiety

  • Mood disorders

  • Delirium
  • Legal problems
  • Death

  • Visual problems
  • Decreased coordination
  • Nausea or vomiting
  • Arrhythmias
  • Violence or aggression
  • Confusion or impaired judgment

Prognosis:

  • The prognosis is fair if inhalants are used short-term.
  • The prognosis is poor if inhalants are used long-term.

Patient Education:

  • Prevention
  • Education about substance abuse
  • Social skills training
  MISCELLANEOUS Section 9 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page Click here to go to the next section in this topic
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Medical/Legal Pitfalls:

  • Failure to know local and state laws is a potential pitfall; persons who abuse inhalants may be placed in jail.

Special Concerns:

  • HIV: Any person who engages in risky behavior that results in impaired judgment (eg, use of drugs, alcohol, inhalants) should be made aware of the risks associated with the acts, especially drug abuse that is known to occur in a subgroup of adolescents aged 12-17 years. Whether the impaired judgment leads to promiscuity, impaired cognitive functioning that can affect driving, or other activities in which accidents can be expected to occur, an awareness of the additional risk of HIV infection must be conveyed. Even tissue damage in the nose associated with huffing, which can cause nosebleeds, can put someone at risk.
  • Pregnancy: The use of inhalants can cause preterm labor, fetal growth retardation, and abnormalities similar to those associated with fetal alcohol syndrome.
  • Conduct disorder: Abuse may be more frequent and extensive, thus worsening treatment outcome.
  • Antisocial personality disorder: Abuse may be more frequent and extensive, thus worsening treatment outcome.
  BIBLIOGRAPHY Section 10 of 10   Click here to go to the previous section in this topic Click here to go to the top of this page
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

  • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994: 243-46.
  • Balster RL: Neural basis of inhalant abuse. Drug Alcohol Depend 1998 Jun-Jul; 51(1-2): 207-14[Medline].
  • Dinwiddie SH: Abuse of inhalants: a review. Addiction 1994 Aug; 89(8): 925-39[Medline].
  • Espeland K: Identifying the manifestations of inhalant abuse. Nurse Pract 1995 May; 20(5): 49-50, 53[Medline].
  • Flanagan RJ, Ives RJ: Volatile substance abuse. Bull Narc 1994; 46(2): 49-78[Medline].
  • Giovacchini RP: Abusing the volatile organic chemicals. Regul Toxicol Pharmacol 1985 Mar; 5(1): 18-37[Medline].
  • Hernandez-Avila CA, Ortega-Soto HA, Jasso A, et al: Treatment of inhalant-induced psychotic disorder with carbamazepine versus haloperidol. Psychiatr Serv 1998 Jun; 49(6): 812-5[Medline].
  • Jones HE, Balster RL: Inhalant abuse in pregnancy. Obstet Gynecol Clin North Am 1998 Mar; 25(1): 153-67[Medline].
  • Kaplan HI, Sadhock BJ: Kaplan and Sadhock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. New York, NY: Williams & Wilkins; 1998: 430-32.
  • Korman M, Matthews RW, Lovitt R: Neuropsychological effects of abuse of inhalants. Percept Mot Skills 1981 Oct; 53(2): 547-53[Medline].
  • Kucuk NO, Kilic EO, Ibis E, et al: Brain SPECT findings in long-term inhalant abuse. Nucl Med Commun 2000 Aug; 21(8): 769-73[Medline].
  • Kurbat RS, Pollack CV Jr: Facial injury and airway threat from inhalant abuse: a case report. J Emerg Med 1998 Mar-Apr; 16(2): 167-9[Medline].
  • Kurtzman TL, Otsuka KN, Wahl RA: Inhalant abuse by adolescents(1). J Adolesc Health 2001 Mar; 28(3): 170-80[Medline].
  • McGarvey EL, Clavet GJ, Mason W, Waite D: Adolescent inhalant abuse: environments of use. Am J Drug Alcohol Abuse 1999 Nov; 25(4): 731-41[Medline].
  • Meadows R, Verghese A: Medical complications of glue sniffing. South Med J 1996 May; 89(5): 455-62[Medline].
  • Misra LK, Kofoed L, Fuller W: Treatment of inhalant abuse with risperidone. J Clin Psychiatry 1999 Sep; 60(9): 620[Medline].
  • National Inhalant Prevention Coalition: National Inhalant Prevention Coalition Web Site. Available at: www.inhalants.org; 2000[Full Text].
  • Oh SJ, Kim JM: Giant axonal swelling in "huffer's" neuropathy. Arch Neurol 1976 AUG; 33(8): 583-6[Medline].
  • Russe BR, McCoy CB, Barton JE: Recent findings concerning inhalant use. Chem Depend 1980; 4(1-2): 113-26[Medline].
  • Santos de Barona M, Simpson DD: Inhalant users in drug abuse prevention programs. Am J Drug Alcohol Abuse 1984; 10(4): 503-18[Medline].
  • Soderberg LS: Immunomodulation by nitrite inhalants may predispose abusers to AIDS and Kaposi's sarcoma. J Neuroimmunol 1998 Mar 15; 83(1-2): 157-61[Medline].
  • Weintraub E, Gandhi D, Robinson C: Medical complications due to mothball abuse. South Med J 2000 Apr; 93(4): 427-9[Medline].
  • Young SJ, Longstaffe S, Tenenbein M: Inhalant abuse and the abuse of other drugs. Am J Drug Alcohol Abuse 1999 May; 25(2): 371-5[Medline].

NOTE:
Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

Inhalant-Related Psychiatric Disorders excerpt

© Copyright 2002, eMedicine.com, Inc.

About Us | Privacy | Code of Ethics | Contact Us | Advertise | Institutional Subscribers