Individuals exposed to amphetamine-type stimulants or cocaine can develop stimu- lant use disorder as rapidly as 1 week, although the onset is not always this rapid. Re- gardless of the route of administration, tolerance occurs with repeated use. Withdrawal symptoms, particularly hypersomnia, increased appetite, and dysphoria, can occur and can enhance craving. Most individuals with stimulant use disorder have experienced tol- erance or withdrawal.
Use patterns and course are similar for disorders involving amphetamine-type stimu- lants and cocaine, as both substances are potent central nervous system stimulants with similar psychoactive and sympathomimetic effects. Amphetamine-type stimulants are longer acting than cocaine and thus are used fewer times per day. Usage may be chronic or episodic, with binges punctuated by brief non-use periods. Aggressive or violent behavior is common when high doses are smoked, ingested, or administered intravenously. Intense temporary anxiety resembling panic disorder or generalized anxiety disorder, as well as paranoid ideation and psychotic episodes that resemble schizophrenia, is seen with high— dose use.
Withdrawal states are associated with temporary but intense depressive symptoms that can resemble a major depressive episode; the depressive symptoms usually resolve within 1 week. Tolerance to amphetamine-type stimulants develops and leads to escalation of the dose. Conversely, some users of amphetamine-type stimulants develop sensitization, characterized by enhanced effects.
When injected or smoked, stimulants typically produce an instant feeling of well—being, confidence, and euphoria. Dramatic behavioral changes can rapidly develop with stimu— lant use disorder. Chaotic behavior, social isolation, aggressive behavior, and sexual dys- function can result from long-term stimulant use disorder.
Individuals with acute intoxication may present with rambling speech, headache, tran- sient ideas of reference, and tinnitus. There may be paranoid ideation, auditory halluci- nations in a clear sensorium, and tactile hallucinations, which the individual usually recognizes as drug effects. Threats or acting out of aggressive behavior may occur. Depres— sion, suicidal ideation, irritability, anhedonia, emotional lability, or disturbances in atten- tion and concentration commonly occur during withdrawal. Mental disturbances associated with cocaine use usually resolve hours to days after cessation of use but can persist for 1 month. Physiological changes during stimulant withdrawal are opposite to those of the intoxication phase, sometimes including bradycardia. Temporary depressive symptoms may meet symptomatic and duration criteria for major depressive episode. Histories con- sistent with repeated panic attacks, social anxiety disorder (social phobia)—like behavior, and generalized anxiety—like syndromes are common, as are eating disorders. One ex- treme instance of stimulant toxicity is stimulant-induced psychotic disorder, a disorder that resembles schizophrenia, with delusions and hallucinations.
Individuals with stimulant use disorder often develop conditioned responses to drug- related stimuli (e.g., craving on seeing any white powderlike substance). These responses contribute to relapse, are difficult to extinguish, and persist after detoxification.
Depressive symptoms with suicidal ideation or behavior can occur and are generally the most serious problems seen during stimulant withdrawal.