To the Editor: Stimulant use to treat attention deficit disorder and stimulant misuse to aid studying has dramatically increased in recent years among college students (1). A phenomenon we have observed is the use of stimulants during the schizophrenia prodrome for presumed attention deficit disorder or attentional difficulties in the absence of any childhood attention deficit disorder. The following case typifies this presentation, which we have seen several times over the past 2 years in our First Episode and Early Psychosis Program.
“Mr. A,” a 20-year-old man, with normal childhood development and no behavioral or academic problems, graduated high school with honors despite regular marijuana use. During his sophomore year, he suddenly found it difficult to concentrate and demonstrated difficulty keeping up with his course work. These difficulties prompted him to try a friend’s prescription stimulant Adderall, which he found effective and continued to use it intermittently without a prescription for "cramming." Several months after starting Adderall, he became acutely psychotic after smoking phencyclidine-laced cannabis at a party. He required a lengthy hospitalization but was eventually stabilized and treated with aripiprazole 10 mg/daily. His request for stimulants “to concentrate better” was resisted, and after 6 months of treatment with aripiprazole, he made a full symptomatic and functional recovery without any objective or subjective residual psychotic or cognitive symptoms. His provisional diagnosis of schizophrenia was confirmed when he had a psychotic relapse 3 months after discontinuing his maintenance antipsychotic aripiprazole following 1 year of treatment.
The prodrome of schizophrenia is characterized by nonspecific symptoms that include cognitive problems, often characterized by patients as “difficulties concentrating.” The construct of “basic symptoms” attempts to capture these nonpsychotic, subjective cognitive problems that begin during the prodrome and might presage the onset of psychosis. Two basic symptoms that would lead to a complaint of “difficulties concentrating” are thought interference (the intrusion of often banal thoughts) and disturbances of receptive language (problems with the meaning of words). Both are of particular interest because of their potential as specific predictors of schizophrenia (2).
College students who present for treatment with self-diagnosed “pseudo-attention deficit disorder” should be asked about misuse of stimulants and followed closely, since a small percentage will be in the early phases of schizophrenia. Although the impact of stimulants on the course of schizophrenia is not known, sensitization has been described with stimulants (3), raising the possibility that stimulant use is a risk factor for some cases of schizophrenia.
1.White BP, Becker-Blease KA, Grace-Bishop K: Stimulant medication use, misuse, and abuse in an undergraduate and graduate student sample. J Am Coll Health 2006; 54:261–268
2.Klosterkoetter J, Hellmich M, Steinmeyer EM, Schultze-Lutter F: Diagnosing schizophrenia in the initial prodromal phase. Arch Gen Psychiatry 2001; 58:158–164
3.Tenn CC, Fletcher PJ, Kapur S: A putative animal model of the "prodromal" state of schizophrenia. Biol Psychiatry 2005; 57:586–593