The typology of substance-induced neurotic and psychotic disorders.

During the last decade substance abuse in Ukraine acquired ubiquitous and increasingly negative impact on the law, social and psychological atmosphere of the society and negative influence on the health of the population. The spread of non-medical drug use among under-age and youth, as well as among women evokes particular concern. The rapid growth of this disease indicates the lack of importance of preventive measures. The existing official treatment and rehabilitation programs also have low efficiency. One of the leading causes of minimal impact of such events is the lack of basic conceptual framework that takes into account the biological, psychological and social causes of addiction, the personality of the patient and his social environment. An important problem in nowadays addiction treatment methodology is co-morbus mental pathology, as well as therapeutic correction of various mental and behavioral disturbances with given nosology of a patient under rehabilitation.


This work is devoted to the study of the whole range of mental disorders that can be diagnosed on the syndrome level in the dynamics of observation of patients who use a variety of psychoactive substances (with a predominant introduction of opiates). The objects of the study were drug addicts presented from the number of patients of the psychotherapeutic drug addiction treatment center in Zaporozhye. 3042 patients that received comprehensive treatment in Medical Center of Dr. Vasylenko have been observed in the course of 10 years (patent number 55863ot23.11.2011.). Neurotic disorders were detected among 67% of patients; they were presented with a predominance of affective pathology observed in the course of abstinence syndrome, during post abstinence period and even in remission. Agreeing with the opinion of many scientists that mood disorders are required in the structure of psychopathological symptoms of patients (Iwaniec N. N., Anokhin I.P. et al, 2004), it draws attention to their different origins. If they are part of abstinence withdrawal syndrome, then external social and micro social factors can be the cause during the remission period (psychogenic options). The type of a psychoactive substance and features of personality influenced the variety of manifestations of this pathology.

The leading position in the picture of non psychotic disorders of patients observed in the group was occupied by anxiety, which represented a kind of psychopathological background, which developed or strengthened other disturbances. The severity of anxiety did not correlate with the severity of withdrawal syndrome. The beginning of emotional discomfort was associated with low self-esteem and the expectation of social and psychological problems. On admission anxiety was diagnosed as episodic and was intensified by manifestations of withdrawal during the first week. It could be supported by external factors: the absence of the desired reaction in the first sessions of group therapy, the misunderstanding of relatives, the presence of concomitant somatic diseases (hepatitis, HIV), the lack of faith in recovering.

Next in frequency and duration is asthenic syndrome that is presented with symptoms of hyper hysterical weakness and reduced threshold of perception. These symptoms lead to extreme sensitivity to physical and emotional influences, and the response was reflected in increased emotionality and rapid exhaustion. One of the related manifestations was emotional lability or increased explosivity. At the peak of this emotions behavioral responses were seen in conflicts relating to accompanying people and personnel or in general unwillingness to continue treatment explaining it as ineffective.
But both these types of reaction were quickly exhausted and short-termed. This was maintained by sleep disorders symptoms and reversible reduction of attention and memory.

The most expressive by its external manifestations was dysphoria with malicious and spiteful affect with angry and destructive actions. The patients themselves searched for a reason to have a conflict. These emotional disorders had paroxysmal character, without medical treatment they repeated even after the reduction of withdrawal syndrome. Patients with a long history of drug treatment (over 10 years), revealed signs of toxic encephalopathy during neurological examination, EEG showed diffuse brain damage, psychological testing determined intellectual and mental defect. Fixation processes suffered and the capacity to accumulate knowledge was violated. The patients had active attention disorder (presumably associated with concomitant asthenia symptoms) as well as mnestic personality disorder. This category of patients was particularly difficult for psychotherapeutic treatment, because after dysphoria’s completion (duration from 20 minutes to 3 hours) the meaninglessness of the problem was obvious to the patient, but he still tried to find and prove his right. A change in the subjective perception of the running of time is an interesting feature that appears. Patients perceive it slowly, one can often hear the statement that the time has "stopped", " stretched" . These conclusions shape a feeling of painfully prolonged stay in the center, and lead to another conflict and impulsive discharge from hospital without discussion with family and doctors.

The depressive symptom was the most diverse, severe and durational. The fact that depression is not as prevalent, as the patients think, draws attention. Often they use the word “depression” to explain all somatic and psychological problems and request immediate prescription of specific medications (sedatives). Depression in the course of withdrawal is common for stimulants users. We observed dreary depression with adynamia, flabbiness, loss of appetite and body weight. The patient is almost all the time in bed, drowsiness with prolonged sleep was marked. During this period, the most significant limitation for patients is the limitation of ability to enjoy the surroundings. Patients tend to speak about the inferiority of their own existence, hopelessness, feeling of inner emptiness and bleak. At the same time they constantly arise memories of happiness during taking psychoactive substances, which may ultimately lead to its search. Early detection of depression and mandatory prescription of antidepressants (mainly selective inhibitors of serotonin reuptake) is complementary to psychotherapeutic work. Another kind of depression diagnosed during withdrawal period, mainly in opiate addiction, is asthenic depressive state, that is sometimes accompanied by ideas of self-blame, and even suicide attempts, dysphoric depression with predominance of irritability, nastiness, hysterical reactions with inclination to auto-aggression.

In some cases the hypochondriacal disorders and anxiety were included into the depressive syndrome. The patients suddenly became overprotective about their physical health, demanded additional examination and regarded with suspicion to satisfactory results of the tests. The switching of the patient’s complaints only to the physical sphere delayed the psychotherapeutic work and the effectiveness of complex techniques. Firm anxiety-like progressive hypochondriacal disorders have determined the development of pathological personality and poor prognosis of the disease. This was particularly evident at the level of delusional experiences, although delirium was not systematized, not resistant, and the ideas themselves were on the verge of overvalued and dominant formations.


The rarest among emotional disorders are manifarma symptoms, which resemble hypomania by their appearance. This similarity concerns only the mood enhance and light motor disinhibition. The patients are careless, cheerful and flexible. After careful observation it is obvious that their gaiety is not mediated by external causes and does not amuse others. In regard to physical disinhibition, rapid exhaustion (signs of fatigue) without any critical attitude of patients to this fact is obvious. Easy-lost control of a situation, slowness, primitive thinking is observed in thinking disorders. Patients easy give promises, but don’t follow them – mostly they forget about them. Drastic impoverishment of speech is noteworthy, adjectives, adverbs and participles disappear from their speech. These symptoms decreased significantly after the abstinence termination, they demanded the inclusion of mood stabilizers in the treatment complex.

Psychotic states that required mandatory medication correction were detected in 7% of observed patients. This percentage is not a real figure of prevalence of psychosis among substance users, as the presence of mental disorders (including psychotherapy and rehabilitation accent) is a contraindication for admission to the center. However, such disorders have evolved in the rehabilitation process, or have not been diagnosed by specialists before. Practice dictates the necessity of proper psychosis qualification, which is of great importance not only for the choice of therapeutic approaches, but also for the prognosis of the disease in general.

All psychoses are divided into those that are developing on the background of intoxication, those that are developing during abstinence syndrome, and sub acute or chronic relapsing psychoses during different periods of remission. The period of drug use, the substance and concomitant somatic and neurological diseases affected their duration and structure.

The clinical picture often presented delirium (2-3 days), with a predominance of visual hallucinations, usually reflecting the fears and concerns. Patient described threatening enemy gangs, terrorists, and groups of aggressive teenagers or other frightening scenes. Rarely auditory hallucinations were joined; they were related thematically and reflected in behavior. Delirious stupor developed on the background of night insomnia, accompanied by motor excitation, daytime behavior was ranked with partial amnesia that lasted for 1-2 days. Psychosis occurred during the intoxication by substances, or at the moment of overdose. Often before hospitalization patients consumed "the last" dose of psychoactive substances, far exceeding their previous daily dose. If the patient used anticholinergic drugs the delirium had some particular features, such as micropsia hallucinations when patients see small animals, insects, with tactile hallucinations at the same time (patients feel running insects over the body and under the skin). This consciousness disorders were accompanied by severe fluctuations of affects (from manifarma symptoms to anxiety and melancholy), manifested by periods of aggressiveness. The withdrawal of psychosis usually occurred through expressed asthenia.

The state of confusion was much rarer. It was detected by distraught look, bewildered mimicry and complete misunderstanding of what is happening around, disorientation in time and space. Patients did not recognize their accompanying relatives, and people, whom they saw for the first time seemed familiar to them. Confusion occurred due to the action of large doses of stimulants, or intolerance to them.

Among psychotic forms, developed during the withdrawal syndrome, delusional psychosis prevailed. Psychological literature is dominated by the view of the rare frequency of such manifestations in opium addiction. According to our observations paranoia is quite common in pathology of these patients (predominant due to use of stimulants and cannabinoids). Apparently, the relatively high frequency of these acute psychoses can be a manifestation of opiate addiction pathomorphism due to a combination of opiate drugs with sedatives; and a history of head injuries and somatic disorders. Clinical manifestations of delusional psychosis are similar. They start with a strong anxiety and fear, a feeling that «all is clear» with formed conjecture about treacherous plans against the patient. Similar conclusions initially cause curiosity and even joy, but soon the feeling of danger prevails and turns into anger and aggression. The delusion conclusions very quickly move to action. These are delusions of persecution, exposure, jealousy; they all have a high degree of "proof system". Some patients combined delusional experiences with manifarma symptoms (increased activity, acceleration of thinking, and swing from euphoric affect to anger). These patients were particularly brutal; conflicts with staff and attendants in this period were significantly increased by craving for a drug. It was mandatory to prescribe atypical neuroleptics (mainly Zyprexa and Risperidone) for at least 2-3 weeks.

Recurrent psychoses in remission were presented among patients who use cannabinoids. They often start with paranoid symptoms. The hallucinatory-paranoid syndrome of Kandinsky-Clérambault and depersonalization syndrome are possible. Usually within 1-2 days occur sleep disorders, unwarranted anxiety, suspicion and irritability. Later poorly systematized delusions are formed and deprived of inner logic with possible elements of paraphrenia. Paranoia has absurd content, combined with verbal pseudohallucinations and elements of psychic automatism. During repeated exacerbations the structure of psychotic experiences is very similar to schizophrenic process, even with deficit symptoms defied. The symptoms of psychoses were remarkable for their stability and poor prognosis even in the course of neuroleptic treatment; it seemed that their duration is formed mainly by endogenous factors rather than intoxication.

Early detection of described mental disorders will enable a comprehensive treatment and rehabilitation in differentiated drug therapy, increase the effectiveness of addiction treatment and also to generate adequate prognosis in each case.