Out line

• Objectives
• Overview of inhalant related disorders
• Epidemiology
• General etiology and pathology
• Clinical diagnosis of inhalant use disorders
• Specifier
• Differential diagnosis
• Course and prognosis of inhalant use disorders
• intoxication and different inhalant related induced disorders
• General management of inhalant related disorders
 Objectives

At the end of the discussion students will be able to

• define Inhalant related disorders.

• describe pathological mechanisms of inhalant related disorders

• diagnose and manage patients with inhalant related disorders.

Overview of Inhalant-Related Disorders

• Inhalant drugs also called volatile substances or solvents are volatile

hydrocarbons that vaporize to gaseous fumes at room temperature and
• are inhaled through the nose or mouth to enter the bloodstream via the
transpulmonary route.
• Persons, especially adolescents, like to inhale these products for their intoxicating
effect
Overview of Inhalant-Related Disorders...

• These compounds are commonly found in many household products and are divided into
four commercial classes:

1. solvents for glues and adhesives;

2. propellants (e.g., for aerosol paint sprays, hair sprays, and shaving cream);

3. thinners (e.g., for paint products and correction fluids); and

4. fuels (e.g., gasoline, propane)

• These drugs are believed to share some similar pharmacological properties despite
their chemical differences
Overview of Inhalant-Related Disorders…

• The fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-
5) excludes:
• anesthetic gases (e.g., nitrous oxide and ether) and

• short-acting vasodilators (e.g., amyl nitrite) from the inhalant-related

disorders, which are classified as other (or unknown) substance-related
disorders.
Overview of Inhalant-Related Disorders…

The section on inhalant-related disorders in the DSM-5 includes three relevant

categories:

• The first category is inhalant use disorder, which is characterized by clinically

significant impairment and/or distress due to a problematic pattern of volatile
hydrocarbon inhalation.
Overview of Inhalant-Related Disorders…

• The second category, inhalant-induced disorders, includes disorders that result from the
toxic effects of inhaled substances.

• Inhalant-induced disorders include

 inhalant intoxication,
 inhalant intoxication delirium, and
 inhalant-induced psychotic, depressive, anxiety, and major and mild neurocognitive
disorder.

• The third category is unspecified inhalant-related disorder.

 Epidemiology

• Inhalant substances are easily available, legal, and inexpensive.

• These three factors contribute to the high use of inhalants among poor persons and
young persons.

• Approximately 6 percent of persons in the United States had used inhalants at

least once, and about 1 percent of persons are current users.

• Inhalant use accounts for 1 percent of all substance-related deaths and less than
0.5 percent of all substance-related emergency room visits.
 Epidemiology…

• About 20 percent of the emergency room visits for inhalant use involve persons
younger than 18 years of age.

• Inhalant use among adolescents may be most common in

 those whose parents or older siblings use illegal substances.

 Individuals with conduct disorder or antisocial personality disorder.

• White users of inhalants are more common than either black or Hispanic users.

• Most users (up to 80 percent) are male

 Etiology

Extrinsic factors

• Inhalant-related disorders have a multifactorial etiology.

• First, availability is important in determining the prevalence of drug use

disorders.
Inhalants are cheap, available in several forms in most households, easily
concealed, legal to possess, and simple to take.
 Etiology…

• Second, inhalant use apparently is rewarding, both through direct

pharmacological action and through the drugs’ social effects.
Under certain circumstances animals repeatedly self-administer inhalants,
showing that these substances have inherently reinforcing properties.
In addition, adolescents usually gather in small groups to use inhalants, and
being a user facilitates entry into the group, socially reinforcing the use
 Etiology…

 Intrinsic factors

• An impulsive and risk-taking temperament may lead some persons to seek the
excitement and danger of inhalant intoxication.
Persons with adolescent conduct disorder or antisocial personality disorder are
prone to taking extreme risks, and many inhalant users have those disorders.
Several studies suggest an association of inhalant use and conduct problems.
 Etiology…

• In addition, school surveys showed that inhalant users were more likely to be
involved with other drugs.

• More of them also had mothers or siblings with alcohol- or drug-related problems.
 Etiology…

• Less respect for parents, less familism i.e

personal values related to family),

less parental monitoring, and

 experiences of trauma within the family unit have all been related to
increased risk of initiation of inhalant use in recent investigations.

• Finally, two studies suggest that, even more than other drug users, inhalant users
report histories of childhood abuse and/or neglect victimization.
 Neuropharmacology

• Sniffing vapor through the nose or huffing (taking deep breaths) through the
mouth leads to transpulmonary absorption with very rapid drug access to the
brain.

• Approximately 15 to 20 breaths of 1 percent gasoline vapor produce several hours

of intoxication.
 Neuropharmacology…

• The effects appear within 5 minutes and can last for 30 minutes to several hours,
depending on the inhalant substance and the dose.

• The concentrations of many inhalant substances in blood are increased when used
in combination with alcohol, perhaps because of competition for hepatic enzymes.

• Although about one fifth of an inhalant substance is excreted unchanged by the

lungs, the remainder is metabolized by the liver.
 Neuropharmacology…

• Much like alcohol, inhalants have the specific pharmacodynamic effects that
are not well understood.

• Inhalants generally act as a central nervous system (CNS) depressant.

 Because their effects are generally similar and additive to the effects of
other CNS depressants (e.g., ethanol, barbiturates, and benzodiazepines),
some investigators have suggested that inhalants operate by enhancing GABA
system.
 Organ Pathology

• Inhalants are associated with many potentially serious adverse effects.

• The most serious of these is death, which can result from

 respiratory depression,

cardiac arrhythmias, asphyxiation,

 aspiration of vomitus, or

 accident or injury (e.g., driving while intoxicated with inhalants).

 Organ Pathology…

• Chronic inhalant users may have numerous neurological problems:

 CT scan and MRI reveal diffuse cerebral, cerebellar, and brainstem atrophy
with white matter disease.
 Several studies of house painters and factory workers who have been
exposed to solvents for long periods also have found evidence of brain atrophy
on CT scans, with decreased cerebral blood flow.
 Organ Pathology…

• Neurological and behavioral signs and symptoms can include:

 hearing loss, peripheral neuropathy, headache, paresthesias, cerebellar signs,
persisting motor impairment, parkinsonism,
 apathy, poor concentration, memory loss, visual-spatial dysfunction, impaired
processing of linguistic material, and lead encephalopathy.
 White matter changes, or pontine atrophy on MRI, have been associated with
worse intelligence quotient (IQ) test results
 Organ Pathology…

• Other serious adverse effects associated with long-term inhalant use include
irreversible hepatic disease or renal damage (tubular acidosis)

• Cardiovascular and pulmonary symptoms (e.g., chest pain and bronchospasm)

as well as GI symptoms (e.g., pain, nausea, vomiting, and hematemesis).
 Organ Pathology…

• There are several clinical reports of toluene embryopathy, with signs such as like
those of fetal alcohol syndrome.
 These include low birth weight, microcephaly, shortened palpebral fissures,
small face, low-set ears, and other dysmorphic signs.
 These babies reportedly develop slowly, show hyperactivity, and have
cerebellar dysfunction.
Clinical features inhalant use disorder

 In small initial doses, inhalants can be disinhibiting and produce

 feelings of euphoria and excitement as well as

 pleasant floating sensations, the effects for which persons presumably use the
drugs.
 Clinical features inhalant use disorder…

 High doses of inhalants can cause:

• psychological symptoms of
fearfulness,
sensory illusions, auditory and visual hallucinations, and distortions of body
size.
• The neurological symptoms can include
slurred speech, decreased speed of talking, and
ataxia.
• Long-term use can be associated with
 irritability, emotional lability, and
impaired memory.
tolerance may develop
 Diagnostic Criteria(DSM-5)

A. A problematic pattern of use of a hydrocarbon-based inhalant substance

leading to clinically significant impairment or distress, as manifested by at least
two of the following, occurring within a 12-month period:

1. The inhalant substance is often taken in larger amounts or over a longer

period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control use

of the inhalant substance.
 Diagnostic Criteria…

3. A great deal of time is spent in activities necessary to obtain the inhalant

substance, use it, or recover from its effects.

4. Craving, or a strong desire or urge to use the inhalant substance.

5. Recurrent use of the inhalant substance resulting in a failure to fulfill major role
obligations at work, school, or home.

6. Continued use of the inhalant substance despite having persistent or recurrent

social or interpersonal problems caused or exacerbated by the effects of its use.
 Diagnostic Criteria…

7. Important social, occupational, or recreational activities are given up or reduced

because of use of the inhalant substance.

8. Recurrent use of the inhalant substance in situations in which it is physically

hazardous.

9. Use of the inhalant substance 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.
 Diagnostic Criteria…

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of the inhalant substance to achieve

intoxication or desired effect.

b. A markedly diminished effect with continued use of the same amount of the
inhalant substance.
 Diagnostic Criteria…

• despite the absence of a separate inhalant withdrawal diagnosis, patients’

complaints of withdrawal symptoms probably should be counted toward a
diagnosis of inhalant use disorder.

• inhalant users with withdrawal signs/symptoms reportedly experience mild

restlessness, inattentiveness, anxiety, and other physical symptoms
 Specifiers

 With current severity:

 Mild: Presence of 2-3 symptoms.

 Moderate: Presence of 4-5 symptoms.

 Severe: Presence of 6 or more symptoms.

 Specifiers…

 Diagnostic specifiers
• 1. If a specific inhalant of abuse is identified, this agent should be specified in
the diagnosis (e.g. toluene use disorder instead of inhalant use disorder).
• 2. But abused inhalants are often mixtures of psychoactive chemicals and it is
frequently difficult to identify a specific inhalant.
• Thus,the diagnosis is often the generic “inhalant use disorder.
 Specifiers…

 Remission specifier
 In early remission: After full criteria for inhalant use disorder were
previously met, none of the criteria for inhalant use disorder have been met for
at least 3 months but for less than 12 months (with the exception that
Criterion A4, “Craving, or a strong desire or urge to use the inhalant
substance,” may be met).
 Specifiers…

 In sustained remission: After full criteria for inhalant use disorder were
previously met, none of the criteria for inhalant use disorder have been met at
any time during a period of 12 months or longer (with the exception that
Criterion A4, “Craving, or a strong desire or urge to use the inhalant
substance,” may be met).
 Specifiers…

 Legality

• In a controlled environment: This additional specifier is used if the individual is

in an environment where access to inhalant substances is restricted.
 Differential Diagnosis

Inhalant exposure (unintentional) from industrial or other accidents.

• This designation is used when findings suggest repeated or continuous

inhalant exposure but the involved individual and other informants deny any
history of purposeful inhalant use.

Inhalant use (intentional), without meeting criteria for inhalant use disorder.

• Inhalant use is common among adolescents, but for most of those individuals,
the inhalant use does not meet the diagnostic standard of two or more
Criterion A items for inhalant use disorder in the past year.
 Differential Diagnosis…

Inhalant intoxication, without meeting criteria for inhalant use

disorder.
• Inhalant intoxication occurs frequently during inhalant use disorder but also
may occur among individuals whose use does not meet criteria for inhalant
use disorder, which requires at least two of the 10 diagnostic criteria in the
past year.
 Differential Diagnosis…

 Other substance use disorders, especially those involving sedating

substances (e.g. Alcohol, benzodiazepines, barbiturates).
• Inhalant use disorder commonly co-occurs with other substance use disorders,
and the symptoms of the disorders may be similar and overlapping.
• To disentangle symptom patterns, it is helpful to inquire about which
symptoms persisted during periods when some of the substances were not
being used.
 Differential Diagnosis…

 Other toxic, metabolic, traumatic, neoplastic, or infectious

disorders impairing central or peripheral nervous system function.
• A history of little or no inhalant use helps to exclude inhalant use disorder as
the source of these problems.
 Differential Diagnosis…

Disorders of other organ systems:

• Individuals with inhalant use disorder may present with symptoms of hepatic
or renal damage, or symptoms of other gastrointestinal, cardiovascular, or
pulmonary diseases.
• A history of little or no inhalant use helps to exclude inhalant use disorder as
the source of such medical problems.
 Course and Prognosis

• The relatively high prevalence of inhalant use in high school surveys, and its
relatively low prevalence in adulthood, led one expert to state that inhalant use
“should be regarded as a passing phase or fad.”

• Although most inhalant users probably do not progress to inhalant use disorder,
the risk of such progression is much greater for those who have used inhalants
than for those who have not.
 Course and Prognosis…

• Among adultsubstance-dependent patients, a history of inhalant use indicated a

significantly enhanced risk of
antisocial personality disorder, depression, anxiety disorders including social
phobia,
 polysubstance use, and injection drug use.
 Course and Prognosis…

• A large national survey reported significant associations between longer duration

of inhalant use and greater likelihood of experiencing
tuberculosis, bronchitis, asthma, sinusitis, tinnitus,

positive HIV/AIDS status, sexually transmitted disease infections,

 anxiety, and depression.

 Inhalant Intoxication

• Inhalant intoxication is a clinically significant mental disorder that occurs during,

or immediately following, the inhalation of volatile hydrocarbons.

• Inhalation of hydrocarbons may be intentional or unintentional (as in the case of

occupational exposures).
 Inhalant Intoxication…

• Inhalation of toxic gases from products such as glues and paints, which often
contain toluene and/or admixtures of other volatile hydrocarbons, can lead to a
constellation of problematic psychological and behavioral impairments.
including dizziness, incoordination, slurred speech, unsteady gait, lethargy,
tremor, depressed reflexes, psychomotor retardation, generalized muscle
weakness, diplopia, stupor or coma, nystagmus, and subjective feelings of
elation or euphoria
 Inhalant Intoxication…

• Two or more of these signs/symptoms occurring contemporaneously, or in close

temporal contiguity, with hydrocarbon inhalation should occasion a DSM-5
diagnosis of inhalant intoxication.

• Other reported concomitants or sequelae of inhalant intoxication include:

• vomiting, aspiration of vomitus, bronchospasm, chest pain, cardiac arrhythmias

or arrest, accidental burns, seizures, illusions, auditory or visual hallucinations,
delusions, perceptions of altered body size, and suffocation in a plastic bag placed
over the mouth and nose.
 Inhalant Intoxication…

• If known, the specific inhalant should be indicated in the DSM-5 diagnosis (e.g.,
butane intoxication instead of inhalant intoxication).

• However, many inhaled products are mixtures of psychoactive hydrocarbons and

it is therefore often difficult to identify the specific agents leading to intoxication .

 Inhalant Intoxication…

• It is assumed that most inhalant users experience intoxication at least once in their
inhalantusing experiences,

• lifetime inhalant intoxication may be relatively common, especially among youth

and in diverse high-risk populations (juvenile and criminal justice, rural, etc.).
 Inhalant intoxication delirium

• DSM-5 provides a diagnostic category for inhalant intoxication delirium, which is

a disturbance of consciousness and a change in cognition that is a direct
physiological consequence of intoxication with inhalants.

• Inhalant intoxication delirium should be diagnosed instead of inhalant intoxication

if disturbances in attention and other cognitive functions predominate in the
clinical picture and are severe enough to warrant clinical attention.
Inhalant-induced major and mild neurocognitive disorder

• Clinical and some research evidence suggests that some inhalant-using adults
develop inhalant-induced neurocognitive disorder.

• For example, among toluene users (average age, 29 years) studied with MRI, the
neuropsychological deficits correlated strongly with the severity of cerebral white
matter abnormalities, and those abnormalities appear to be caused by inhalants.
Inhalant-induced major and mild neurocognitive
disorder…

 The cardinal feature of major neurocognitive disorder is a significant decline in

level of performance in one or more cognitive domains such that the affected
individual experiences problems in the performance of instrumental activities of
daily living.
 The cognitive impairments can include disturbed executive functioning (i.e.,
planning, organizing, sequencing, and abstracting),
 deficits in learning and memory, and difficulties with language, social cognition,
and perceptual-motor abilities.
 Inhalant-induced major and mild neurocognitive
disorder…

• The symptoms must represent a decrement from earlier functioning, not occur
exclusively in the course of a delirium, and persist beyond the usual duration of
inhalant intoxication.

• Most affected persons will meet criteria for a moderate/severe inhalant use
disorder.
Inhalant-induced major and mild neurocognitive
disorder…

Inhalant-induced mild neurocognitive disorder differs from inhalantinduced

major neurocognitive disorder primarily in that the impairment(s) identified
represent(s) a “modest” rather than “significant” decline in level of performance
of one or more cognitive capacities and the deficits identified do not interfere with
complex instrumental activities of daily living.
 Inhalant-induced psychotic disorder

• The essential features of inhalant-induced psychotic disorder are hallucinations or

delusions judged by laboratory tests, history, or physical examination to be due to
the direct physiological effect of inhalant substances.

• Such psychotic symptoms sometimes develop during intoxication with inhalants;

therefore, this diagnosis applies to patients who meet criteria for inhalant
intoxication but who also have psychotic symptoms in excess of those usually
associated with inhalant intoxication.
 Inhalant-induced psychotic disorder…

• The psychotic symptoms must cause clinically significant functional impairment

and/or distress and be severe enough to warrant independent clinical attention.

• This diagnosis is not made in the presence of inhalant intoxication delirium.

Inhalant-Induced Mood Disorder and Inhalant-Induced
Anxiety Disorder

• Inhalant-induced mood disorder and inhalant-induced anxiety disorder allow the

classification of inhalant-related disorders characterized by prominent mood and
anxiety symptoms.

• Depressive disorders are the most common mood disorders associated with
inhalant use, and panic disorders and generalized anxiety disorder are the most
common anxiety disorders.
 Unspecified Inhalant-Related Disorder

• The diagnosis of unspecified inhalant-related disorder is reserved for inhalant-

related clinical presentations associated with clinically significant distress and/or
functional impairment that do not meet full diagnostic criteria for any specific
inhalant-related disorder.
 Unspecified Inhalant-Related Disorder…

• Fore example
nitrous oxide-related disorders, and

amyl, butyl, and isobutyl nitrite-related disorders

• DSM-5 includes the above disorders among other (or unknown) substance-related
disorders because of differences between in modes of action and associated
problems from inhalantes.
 General managements

1. TREATMENT

Inhalant intoxication, as with alcohol intoxication, usually requires no medical

attention and resolves spontaneously.
• However, effects of the intoxication, such as coma, bronchospasm,
laryngospasm, cardiac arrhythmias, trauma, or burns, need treatment.
• Otherwise, care primarily involves reassurance, quiet support, and attention to
vital signs and level of consciousness.
• Sedative drugs, including benzodiazepines, are contraindicated
 General managements…

No established treatment exists for the cognitive and memory problems of
inhalant induced persisting dementia.
• Street outreach and extensive social service support have been offered to
severely deteriorated, inhalant-dependent, homeless adults.
• Patients may require extensive support within their families or in foster or
domiciliary care.
 General managements…

The course and treatment of inhalant-induced psychotic disorder are like those of
inhalant intoxication.
• The disorder is brief, lasting a few hours to (at most) a very few weeks
beyond the intoxication.
• Severe agitation may require cautious control with haloperidol
 General managements…

Inhalant-induced anxiety and mood disorders may precipitate suicidal ideation,

and patients should be carefully evaluated for that possibility.
• Antianxiety medications and antidepressants are not useful in the acute phase

of the disorder; they may be of use in cases of a coexisting anxiety or

depressive illness.
 General managements…

2. Day Treatment and Residential Programs:

• This has been used successfully, especially for adolescent abusers with
combined substance dependence and other psychiatric disorders like
conduct disorder

major depressive disorder, dysthymic disorder, and PTSD

• Attention is also directed to experiences of abuse or neglect, which is very

common in these patients
 General managements…

• Both group and individual therapy are used that are behaviorally oriented,
with immediate rewards for progress toward objectively defined goals in
treatment and punishments for lapses to previous behaviors.

• The patients’ families, often very chaotic, are engaged in modifications of

structural family therapy
 General managements…

• Progress is monitored with urine and breath samples analyzed for alcohol and
other drugs at intake and frequently during treatment.

• Treatment usually lasts 3 to 12 months.

• Termination is considered successful if the youth has practiced a plan to stay

abstinent is showing fewer antisocial behaviors.
 References

• KAPLAN & SADOCK’S comprehensive textbook of psychiatry tenth edition

• KAPLAN & SADOCK’S Synopsis of Psychiatry Behavioral Sciences/Clinical

Psychiatry Eleventh Edition

• DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

FIFTH EDI T ION
 h an k yo u
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