Section 3: Self reporting questionnaire (SRQ)
3: Managing aggressive or agitated behaviour
• Tip Sheet 1: Dose effects of amphetamines & Effects of methamphetamine use
• Tip Sheet 2: Managing acute toxicity
• Tip Sheet 3: Managing aggressive or agitated behaviour
Cl C li in n ic i ca al l c cr ri it te er ri ia a
According to the Diagnostic and Statistical Manual of Mental Disorders IV‐TR (DSM‐IV‐TR) dependence is characterised by a person experiencing at least three of the following symptoms:
• tolerance, defined as either a need to use larger amounts to achieve desired effect, or decreased effect with continued use of the same amount of substance;
• withdrawal;
• increased dosage and duration of the substance use;
• unsuccessful attempts to cut down or control substance use;
• increased time spent to obtain the substance, use the drug or come down from the drug;
• giving up social, occupational and recreational activities because of substance use; and
• continued substance use despite knowledge of having an awareness of negative consequences (e.g., physical or psychological problems) (American Psychiatric Association (APA), 2000)
Additionally, the DSM‐IV‐TR (APA, 2000) provides a diagnostic criteria for amphetamine intoxication:
A. The patient has recently used an amphetamine or related substance, such as methylphenidate.
B. Clinically significant maladaptive behavioural or psychological changes developed during or shortly after the patient used amphetamines or a related substance. Such changes include the following:
Euphoria or affective blunting Changes in sociability
Hypervigilance
Interpersonal sensitivity Anxiety, tension, or anger Stereotyped behaviours Impaired judgment
Impaired social or occupational functioning
C. Two or more of the following conditions develop during or shortly after the patient used amphetamines or a related substance:
Tachycardia or bradycardia Pupillary dilatation
Elevated or lowered blood pressure Perspiration or chills
Nausea or vomiting Evidence of weight loss
Psychomotor agitation or retardation
Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias Disorientation and memory loss, seizures, dyskinesias, dystonias, or coma D. The symptoms are not due to a general medical condition, and another mental disorder does
not account for them better than amphetamine intoxication does.
The DSM‐IV‐TR (APA, 2000) also describes the following 10 amphetamine‐related psychiatric disorders:
1. Amphetamine‐induced anxiety disorder 2. Amphetamine‐induced mood disorder
3. Amphetamine‐induced psychotic disorder with delusions 4. Amphetamine‐induced psychotic disorder with hallucinations 5. Amphetamine‐induced sexual dysfunction
6. Amphetamine‐induced sleep disorder 7. Amphetamine intoxication
8. Amphetamine intoxication delirium 9. Amphetamine withdrawal
10. Amphetamine‐related disorder not otherwise specified
Either prescription or illegally manufactured amphetamines can induce these disorders. Prescription amphetamines are used frequently with children and adolescents to treat attention deficit hyperactivity disorder (ADHD), and they are the most commonly prescribed medications for children.
Amphetamine‐related psychiatric disorders are conditions resulting from intoxication or long‐term use of amphetamines or Amphetamine‐type Stimulants (ATS). These disorders can also be experienced during the withdrawal period and are often self‐limiting after cessation, though, in some cases, psychiatric symptoms may last several weeks after discontinuation. This is particularly important for treatment agencies to understand, since it is often after the person has been accepted into treatment in, for example, a therapeutic community, that symptoms present.
For some people, this will include paranoia during withdrawal as well as during sustained use.
Amphetamine use may also elicit or be associated with the recurrence of other psychiatric disorders.
People addicted to amphetamines sometimes decrease their use after experiencing paranoia and auditory and visual hallucinations (Larson, 2008).
The symptoms of amphetamine‐induced psychiatric disorders can be differentiated from those of related primary psychiatric disorders by time. If symptoms have not resolved within two weeks after discontinuation of ATS, it is advised that a primary psychiatric disorder should be suspected (Larson, 2008). Depending on the severity of symptoms, symptomatic treatment can be delayed to clarify the etiology. However, it is important that TCs gain the support of mental health services and consult with a psychiatrist to better assess problems related to ATS use and withdrawal.
Amphetamine‐induced psychosis (delusions and hallucinations) can be differentiated from psychotic disorders when symptoms resolve after ATS withdrawal. Absence of symptoms, including anhedonia (the inability to gain pleasure from enjoyable experiences), avolition (a psychological state characterised by general lack of desire, drive, or motivation to pursue meaningful goals), amotivation (the inability or unwillingness to participate in normal social situation), and flat affect, are further indicators of amphetamine‐induced psychosis (Larson, 2008).
Amphetamine‐induced delirium follows a reversible course similar to other causes of delirium, and it is identified by its relationship to amphetamine intoxication. After the delirium subsides, little to no impairment is observed. Delirium is not a condition which has been observed during amphetamine withdrawal (Larson, 2008).
Mood disorders similar to hypomania and mania may be observed during ATS intoxication.
Depression may also result during withdrawal, and repeated use of ATS can produce antidepressant‐
appear in a fashion similar to mood disorders (Larson, 2008). During intoxication, sleep can be decreased markedly. This was observed by many of the TCs during the consultation process as being one of the concerns in the early stages of treatment, with the after‐effect, being the need for more sleep. This is part of the withdrawal process. A disrupted circadian rhythm can result from late or high doses of ATS.
Amphetamine‐related disorder not otherwise specified is a diagnosis assigned to those who have several psychiatric symptoms associated with amphetamine use but do not meet the criteria for a specific amphetamine‐related psychiatric disorder (APA, 2000).
Cl C li in n ic i ca al l h hi is s to t or r y y
Amphetamine‐related psychiatric disorders can be confused with psychiatric disorders caused by organic, medical, neurologic, and/or psychological etiologies. The causes of amphetamine‐related psychiatric disorders may be determined by assessing the client's history and developing a genogram.
The DSM‐IV‐TR (APA, 2000) provides criteria helpful for determining if the person is in a state of intoxication or withdrawal. The criteria helps clinicians distinguish disorders occurring during intoxication (e.g., psychosis, delirium, mania, anxiety, insomnia) from those occurring during withdrawal (e.g., depression, hypersomnia).
1. Developmental history: The developmental history provides information about the client's in utero exposure to medications, illicit drugs, alcohol, pathogens, and trauma.
o As children, clients may have had prodromal symptoms of psychiatric disorders, such as social isolation, deteriorating school performance, amotivation, avolition, anhedonia, sleep disturbances, sexual paraphilias, poor interest, psychomotor retardation, demoralisation, social isolation, and suicidal thoughts and behaviours.
o Delinquency, truancy, educational failure, early use of drugs and alcohol, oppositional behaviour associated with conduct disorder, and use of ATS are developmental behaviours that suggest an amphetamine‐related psychiatric disorder.
2. Psychiatric history: Two issues are emphasised:
o Determine whether a psychiatric disorder or symptoms ever occurred when the client was not exposed to amphetamines.
o Determine whether the client ever had a psychiatric disorder or symptoms similar to the present symptoms in relation to any other drug or medication.
3. Recent history: The client's history of ATS use is the most important factor and is determined by asking the following questions:
o When did ATS use start?
o What is the nature of ATS use (e.g., speed, methamphetamine, and if so, what type?)
o How often does the person use ATS?
o How much is being used?
o Is the person currently intoxicated or in withdrawal?
o Has the client recently increased his or her ATS use or started to binge?
4. Substance abuse history: Take a full substance use history.
5. Family history: A family history of a psychiatric disorder may suggest a primary psychiatric disorder. A diagnosis of amphetamine‐related psychiatric disorder might still be possible if the client has no family history of psychiatric disorder.
Wi W it th h dr d ra a wa w a l l
The DSM‐IV‐TR (APA, 2000) criteria for amphetamine withdrawal are as follows:
A. Cessation of (or reduction in) use that has been heavy or prolonged.
B. Dysphoric mood and two (or more) of the following physiological changes developing within a few hours to several days after Criterion A:
1. Fatigue
2. Vivid, unpleasant dreams 3. Insomnia or hypersomnia 4. Increased appetite
5. Psychomotor retardation or agitation
C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The symptoms are not due to a general medical condition, and are not better accounted for by another mental disorder.
Me M et th ha a mp m ph he et ta a mi m in ne e w wi it t hd h dr ra aw wa al l
Lee and associates (2007) in Clinical Treatment Guidelines for Alcohol and Drug Clinicians. No 14:
Methamphetamine dependence and treatment, detail methamphetamine withdrawal syndrome as predominantly characterised by adverse psychological symptoms, such as extreme fatigue and irritability. The DSM‐IV‐TR characterises methamphetamine withdrawal as including dysphoric mood (sadness) plus two of the following:
• fatigue
• insomnia
• hypersomnia (over‐sleeping)
• psychomotor agitation
• increased appetite
• vivid, unpleasant dreams (APA, 2000).
Drug cravings, paranoid or suspicious thoughts, and feeling angry, aggressive or emotional are other symptoms commonly associated with methamphetamine withdrawal. Withdrawal symptoms from methamphetamine may mimic the symptoms of acute intoxication, particularly agitation and hyper‐
arousal (Jenner & Saunders, 2004). While there is some evidence to suggest that the majority of symptoms of withdrawal will resolve within a week of ceasing methamphetamine use, with sleep and appetite related symptoms persisting for a further one to two weeks (McGregor, Srisurapanont, Jittiwutikarn, Laobhripatr, et. al., 2005) this may be influenced by a number of factors:
• age (older and more dependent users may experience a more severe withdrawal)
• general health
• mode of administration
• quantity and purity of methamphetamine being used prior to cessation
• polydrug use
persist for longer periods, with the consensus being that clients may experience symptoms for up to four to six weeks, and that up to the first 12 weeks of treatment may be adversely affected.
Dependent users are also likely to undergo withdrawal many times as use fluctuates between heavy use, regular use and periods of intermittent or binge use. Self‐detoxification is common and polydrug use by ATS users may serve the purpose of managing some of this process.
TCs are amongst the specialist services that are most likely to see methamphetamine users who have suffered from depression, experienced psychotic symptoms such as hallucinations and paranoia, or have experienced behavioural problems, such as aggressive outbursts. All of these behaviours were reported as part of the consultation process. These clients require skilled clinicians and a range of resources in order to manage these complexities.
Ma M a na n ag ge em me en n t t o of f c co om mo or rb b id i d p ps sy yc ch ho o si s is s
A small, but significant percentage of users will experience methamphetamine‐induced psychosis.
Typically, this will occur following heavy binge or prolonged use, however, little is known about Australian prevalence rates (Dawe & McKetin, 2004).
Lee and associates (2007) report that symptoms of a methamphetamine‐induced psychosis usually resolve within a few days after ceasing use. Nevertheless, this can be an extremely stressful event, with clients worrying that their use of methamphetamine may lead to a permanent psychotic disorder. During the consultations some TCs reported this occurrence, sometimes leading to clients being treated by mental health teams and in some cases, being admitted to psychiatric care for a period of time before returning to the TC.
Clinicians should be aware that a period of abstinence (from methamphetamine) and improved self‐
care is likely to alleviate many symptoms without psychiatric intervention. However, in a small group of users, symptoms may worsen immediately after cessation of methamphetamine use (during withdrawal) but usually settle over a relatively short period of time – a matter of days or weeks (Lee, et.al., 2007). If symptoms resolve within a month of ceasing methamphetamine use, it is likely to have been a drug‐induced psychosis. For others, psychotic symptoms may persist for a longer period of a month or more (Dawe & McKetin, 2004). This may suggest a more enduring psychiatric condition.
The issue of whether or not the symptoms of psychosis have been triggered by methamphetamine or other drug use, or whether there was a pre‐existing vulnerability to schizophrenia has often concerned those working in both the AOD and mental health fields (Dawe & McKetin, 2004). In the acute phase, this issue is not of immediate concern. At this point, the presenting symptoms rather than the underlying cause are the treatment focus. If psychotic symptoms worsen during treatment, then it is likely that there is an underlying mental health issue and psychiatric assessment and intervention may be required. Acute symptoms should be managed as a priority (Lee, et.al., 2007).
A number of TCs reported having clients on ongoing anti‐psychotic medications where symptoms had not abated, and in some cases had increased. Once medication is stabilised, the person is generally able to continue within the TC and to take part in all program interventions. The treatment protocol should be offered once the symptoms of psychosis have resolved.
Wh W he en n a an nd d h ho ow w t to o r re ef fe er r t to o m me en nt ta al l h he ea al lt t h h s se er rv vi ic ce es s
All TCs in the consultation reported having professional relationships, including Memoranda of Understanding, with mental health services. Many had a consultant psychiatrist as part of the program clinical team. Lee and colleagues (2007) note there are four main reasons for making contact with a mental health service on behalf of a client. These are:
1. If it is suspected that the client has an undiagnosed or untreated psychotic disorder.
For example, if the client appears to hear or see things that others don’t (hallucinations) or to hold delusional beliefs or to demonstrate bizarre behaviour – especially if these symptoms persist after a period of detoxification and stabilisation.
2. If there is a concern that the client has an undiagnosed or untreated bipolar disorder, as indicated by the presence of manic symptoms such as a decreased need for sleep or food, a marked period of productivity, a rapid flow of thoughts or speech and an exaggerated sense of self‐esteem or invincibility.
3. If there is a concern or a high risk of suicide or self‐harm.
4. If there is a concern about the person’s ability to respond to treatment.
All TCs reported staff had an improved ability to respond to comorbid presentations, and all reported a level of mental health training. Nevertheless, the need to maintain specialist service relationships was seen as both a concern and a priority by all during the consultation phase.
Of particular concern for TCs was a belief that in some cases mental health services had possibly viewed the TC as a ‘safe place’ for the client and therefore, after assessment, the intervention which the TC had expected, had not been delivered. This did not necessarily mean removal of the person from the TC into mental health care, but a better process of joint case management between the TC and mental health services. Balancing the needs of the individual against those of the community when a crisis occurs was reported as a concern for many TCs.
The need for better communication between mental health and TCs was therefore cited as a priority.
Included in this is the need to educate mental health and other medical services about the capacity of TCs to respond to crisis situations and to work with people with comorbid presentations. It is clear that TCs do work with very chaotic and complex clients. However, all noted that the balance within the community, including the numbers of clients within the program with complex behaviours, is something which needs to be continually monitored. This is especially important in the early stages of treatment, since it is likely that TCs will primarily deal with these issues during this phase. Hence there is a concern expressed by TCs regarding the number of clients and their degree of complexity in relation to comorbidity concerns, which the TC can admit and adequately treat, at any one time.
The point at which clients often stabilise is also the point at which they may move to the second stage of the program. Therefore it is during the early treatment phase that TCs require increased support.
S S e e c c t t i i o o n n 1 1 : :
C C l l i i n n i i c c a a l l A A s s s s e e s s s s m m e e n n t t
Co C om mp p re r eh he en ns si iv ve e a as ss s es e s sm s me en nt t
Conducting a comprehensive assessment is the first important step in developing a treatment plan for the client. It provides a baseline of information from which treatment can be designed and implemented. All TCs currently have in place an assessment process and protocol which have been designed to meet their needs. This treatment package will not therefore duplicate any of this general material, but will provide some additional materials which may be used to assist assessment.
Also provided is a mental health assessment format for consideration. However, TCs that have already adopted the PsyCheck materials will be familiar with this material and others may already have in place assessment formats to collect the information. Where these are not already in place, it would be useful to review current materials in relation to those provided within this treatment package.
The majority of people who use methamphetamines are polydrug users, and therefore ATS use is seen in conjunction with other drug use. As reported as part of the consultation process, mental health symptoms are common and at least require screening for all methamphetamine users.
Engagement is often cited as a barrier to treatment for methamphetamine users, therefore it is important to assess readiness for treatment as part of this process (Lee, et.al., 2007).
Lee and colleagues (2007) outline the necessary core elements of the drug use component of assessment for methamphetamine users as including:
• accurate information about all aspects of methamphetamine use
• indicators of severity of dependence, withdrawal symptoms and significant periods of abstinence
• evidence of dependence on, or withdrawal from other drugs
• risk behaviour associated with mixing drugs, including overdose or toxicity
• psychosocial factors
• treatment goals
The assessment or clinical interview is also important in order to gather accurate information about:
• type/s of methamphetamine being used
• the quantity and frequency of use
• the route of administration
• duration of use
The differences in drug use patterns between Australian and New Zealand ATS users, and particularly methamphetamine users, were evident during the consultation process. It is important to gather information about polydrug use, with a particular emphasis on the pattern of drug use in relation to methamphetamine use, such as mixing other drugs with methamphetamines and using other drugs (particularly depressants) to alleviate the ‘come down’ effects of methamphetamine.
Lee and colleagues (2007) provide a timeline follow back (TLFB) worksheet as a validated method of understanding the recent pattern of drug use in relation to methamphetamine use, which may be used in conjunction with the clinical interview (see Worksheet 1: Timeline follow back). This is a calendar that records the last 30 days of use and may be of particular benefit with clients during the assessment and pre‐admission stage of treatment. It is suggested that anchors for the client should be provided by indicating public holidays, significant personal events and other dates on the calendar. The client should then be assisted to work back from the last day of use and complete information about all drug use for each day.
As A ss se es ss s in i ng g r re ea ad di in ne es ss s f fo or r c ch ha a ng n ge e
All TCs will be familiar with the Stages of Change Model and the use of Motivational Interviewing in assessing the client’s readiness for change. While the client may already have completed detoxification prior to engagement with the TC, it is particularly important to explore readiness for
All TCs will be familiar with the Stages of Change Model and the use of Motivational Interviewing in assessing the client’s readiness for change. While the client may already have completed detoxification prior to engagement with the TC, it is particularly important to explore readiness for