There are many psychiatric conditions which may be comorbid with cocaine use disorder.

Anxiety disorders, antisocial personality disorder, and attention deficit hyperactivity disorder, can predate the development of stimulant (cocaine) use disorder.

Patients with stimulant (cocaine) use disorder can also have major depressive disorder, bipolar disorder, cyclothymic disorder, or various anxiety disorders. Because cocaine also creates depression (in withdrawal), euphoria, aggression, irritability, mood lability, anxiety, and even psychotic symptoms, the diagnosis of a primary mood or psychotic disorder can be difficult if an individual is actively using cocaine. Therefore, a period of abstinence lasting up to several months may be required before an accurate diagnosis of other disorders can be made. In addition, stimulant (cocaine) use disorder is often accompanied by other substance use disorders, especially those associated with opiates and alcohol-these drugs are often used to temper the irritability and hypervigilance that can follow cocaine intoxication and withdrawal.


Cocaine is a very addictive substance, with studies showing that up to one in six persons who use cocaine will develop a cocaine use disorder.

Cocaine intoxication can produce numerous behavioral and physiologic changes.

Individuals candevelop hallucinations (both auditory and visual), paranoia, delusions, and risk-taking behavior (including promiscuity and violence).

There can be serious physical health risks associated with cocaine use, including cerebral infarctions, transient ischemic attacks, seizures (including status epilepticus), myocardial infarctions, and cardiomyopathies.







Because cocaine delivers a particularly positive and reinforcing high, most users do not seek treatment voluntarily until the behavioral patterns have resulted in significant impairment in functioning (job and relationship losses, legal consequences) or health problems. Craving for cocaine is often so intense that a patient may need to be initially entered into residential treatment in order to establish abstinence from the drug.

Treatment must be multimodal, including medical, psychological, and social strategies to help the patient establish and maintain abstinence. Frequent unscheduled urine toxicology screenings are essential in both short- and long-term treatment of stimulant (cocaine) use disorder, as denial is a prominent aspect of all addictions. Individual and group therapies can focus on support, education, and reduction of denial, as well as on building skills to avoid further drug use. Various behavioral therapies (clinical management, coping skills approaches, motivational interviewing) have been shown to help reduce cocaine use. Narcotics Anonymous sponsors a well-known, widely available, and free group therapy that offers all of the previously mentioned components. Family therapy can also be helpful in confronting both the patient, with the effects of his or her drug-related behavior, and the family, with ways they enable or reinforce the addictive behavior. Social interventions can include abstinence-focused housing programs and vocational training. Unlike in alcohol and opiate addictions, somatic treatments (eg, antidepressants, mood stabilizers, dopamine agonists, and acupuncture) have not been consistently shown to reduce cocaine craving; research in this area continues to be pursued. However, psychotropic medications such as antidepressants, anxiolytics, or mood stabilizers are indicated for treating any comorbid psychiatric illnesses in patients with stimulant (cocaine) use disorder.

Case Correlation

  • See also Case 6 and Case 8 for patients who might present with the same symptoms of euphoria and/or hypervigilance which may be present in individuals with stimulant intoxication. Schizophrenia and bipolar disorder, however, are longer lasting than the half-life of a stimulant, and do not present with the signs and symptoms of stimulant intoxication that are described in category C of the diagnostic criteria (tachycardia, pupillary dilation, perspiration or chills, etc).



Stimulant (cocaine) withdrawal typically lasts 2 to 4 days, although can be longer in heavy users. The "crash" is commonly accompanied by dysphoria, irritability, fatigue, increased appetite, psychomotor agitation or retardation, vivid/unpleasant dreams, and insomnia or hypersomnia. Patients can develop marked depressive symptoms with suicidal ideation and can require hospitalization. They frequently experience strong cravings for the drug during the withdrawal period.




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A 50-year-old homeless male veteran is brought to the emergency department by the police for disruptive behavior. On mental status examination, he has an elevated affect, but also has psychomotor agitation and paranoia; he says he "feels fantastic" but is wary of answering any questions, quickly becoming irritated. On physical examination, the patient exhibits a moderately elevated blood pressure and pulse rate. He is most likely intoxicated with which of the following substances?

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The correct answer is D. You answered D.

D. Cocaine (or other stimulants such as amphetamine) intoxication can present with euphoria, irritability, anxiety, and psychotic symptoms such as paranoia, as well as with elevated vital signs. Conversely, intoxication with alcohol, barbiturates, benzodiazepines, and opiates generally causes depression, somnolence, and depressed vital signs.



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