Cannabis, stimulants and psychosis. Commentary on Gururajan et al. (2012): drugs of abuse and increased risk of psychosis development

A rare case of complete male genital self-amputation posing challenges in the psychiatric diagnosis and management

Genital self-mutilation (GSM) is a rare phenomenon encountered mostly within the context of severe mental illness. The following case report highlights a rare case of self-inflicted total penile self-amputation in a patient with a psychiatric history of polydrug abuse and attention deficit disorder (ADD). The patient engaged in penile self-amputation under the influence of command hallucinations and religious delusions. He was operated on with microsurgical penile replantation but the penis had to be amputated after two weeks because of postoperative complications. The patient was admitted for compulsory psychiatric treatment. During the prolonged hospitalization course, he was arrested for stabbing two other patients and was transferred to a forensic psychiatric unit. The case fits the description for Klingsor Syndrome and involved multiple interacting risk factors that complicated the initial presentation and the ensuing management of the condition in the hospital setting.

Stimulant use disorders in people with psychosis: a meta-analysis of rate and factors affecting variation

OBJECTIVE

Stimulant abuse and dependence often complicate the care of people with psychotic disorders. This study systematically reviews the prevalence estimates reported for stimulant abuse and dependence in people with psychotic disorders, and examines personal, clinical, regional and methodological factors which explain variation in these rates.

METHODS

PsychINFO, EMBASE and MEDLINE (1946-2013) were searched systematically for studies reporting on stimulant drug use disorders in representative samples of people with psychotic disorders. Random effects models estimated the pooled rate of a stimulant use disorder, defined to include stimulant abuse and stimulant dependence. Study characteristics associated with heterogeneity in rates of stimulant use disorder were examined by subgroup analyses for categorical variables, by meta-regression for continuous independent variables and by multiple meta-regression.

RESULTS

Sixty-four studies provided 68 estimates of lifetime or recent stimulant use disorders in 22,500 people with psychosis. The pooled rate of stimulant use disorder was 8.9% (95% CI 7.4%, 10.5%). Higher rates of stimulant use disorders were reported in studies of affective psychosis, studies from inpatient settings, studies from the USA and Australia, and studies with higher rates of cannabis disorder; in multiple meta-regression analysis these factors explained 68% of between-study variance. Rates of stimulant use disorder were stable over time, and unrelated to age, sex, stage of psychosis, type of stimulant drug or study methodology factors.

CONCLUSIONS

Reported rates of stimulant use disorder in people with psychosis are much higher than in the general population but vary widely and are associated with regional, service setting and clinical differences between studies. It is likely that stimulants contribute to the overall burden of psychosis, and that social and environmental factors combine with drug and illness-related factors to influence stimulant use in psychosis.