Substance-induced psychotic disorder: definition, causes, symptoms, and treatments

The substance-induced psychotic disorder is a type of psychotic disorder that people develop due to drug abuse or when withdrawing. Alcohol can also trigger symptoms of psychosis. Unlike many other psychotic disorders, this one is temporary, but it does make a person more susceptible to experiencing psychotic symptoms in the future.

The causes of substance-induced psychotic disorder are stroke or traumatic brain injury, personal history of schizophrenia, and genetic abnormalities.

The main symptoms of substance-induced psychotic disorder are hallucinations, delusions, and paranoia.

Types of substance-induced psychotic disorder revolve around substances abused and include alcohol, cocaine, cannabis, amphetamines, methamphetamine, club drugs such as MDMA and ecstasy, and psychedelic drugs such as LSD.

The treatment for substance-induced psychotic disorder includes medications and therapy. Medically-supervised detox is necessary for treating this disorder in people with addiction.

What is substance-induced psychotic disorder?

The substance-induced psychotic disorder is a mental health condition that involves symptoms of psychosis within a month of using or withdrawing from drugs or alcohol. Known as toxic psychosis, drug-induced or alcohol-used psychosis, the condition may occur due to illicit and prescription drugs alike.

The condition is included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in the chapter called Schizophrenia and Other Psychotic Disorders. As DSM-5 reports, between 7% and 25% of people receiving treatment for the first psychotic episode have a substance-induced psychotic disorder.

Drugs and substances associated with this psychotic disorder include amphetamines, cannabis, alcohol, cocaine, opioids, hallucinogens, phencyclidine (PCP), and sedatives or hypnotics. Excessive and chronic intake of alcohol can also induce symptoms of psychosis.

According to a study from the Frontiers in Psychiatry, illicit substances in particular have psychotomimetic properties. The use of these substances can produce transient psychotic symptoms that result from acute intoxication.

Substance-induced psychosis may involve multiple mechanisms such as higher levels of central dopamine, antagonist activity of NMDA receptors, and activation of receptors with the use of alcohol and drugs.

Information about the history of substance-induced psychotic disorder is scarce. What we do know is that the concept of psychosis stems from 1845 when the term was coined. But even before that, since ancient times, physicians were interested in unique cases where people’s perception of reality was flawed or false. Initially, the term psychosis was used as a synonym for mental illness until 1859 when German psychiatrist Carl Friedrich Flemming utilized the term to refer to mental disorders with identifiable organic findings and disorders of the soul which were believed to have an organic cause.

Several years later, in 1877, Flemming doubled down on his accentuation of psychotic pathology with organic roots. In the first half of the 20th century, psychiatrists and physicians gained more understanding of psychosis and discovered that psychotic symptoms aren’t products of a particular physical illness, rather a wide range of physical diseases that lead to psychic syndrome.

The concepts of psychosis and neurosis were in dichotomy until DSM-2 where it was explained that psychosis features severe functional impairment. The biggest distinction between the two came in DSM-4 which had a chapter Schizophrenia and Other Psychotic Disorders that included conditions where psychotic symptoms are dominant. That’s the same classification present in DSM-5 today.

How common is substance-induced psychotic disorder?

Substance-induced psychotic disorder is not an uncommon occurrence in clinical practice, especially in emergency departments. The prevalence of this disorder depends on the drug abused. Around 20 million people ages 12 and older have substance use disorder in the U.S.

However, a paper from Psychiatry Research showed that the prevalence of substance-induced psychotic disorder is 36.5% in people who misuse methamphetamine.

The journal Comprehensive Psychiatry published a study that examined the presence of psychotic symptoms in people with different types of substance abuse. The prevalence of psychosis in amphetamine abusers was 5.2% to 100%, between 12.4% and 80% for cannabis, 6.7% to 80.7% for cocaine, and 6.7% to 58.2% for opiates.

According to a review from the Frontiers in Psychiatry, the prevalence of this disorder among LSD users is 20.9%, and for psilocybe mushrooms, 18.8%.

At this point, there is no information regarding the prevalence of the substance-induced psychotic disorder in children, teens, and the elderly. In a study published by the journal European Psychiatry, 70.37% of 27 adolescent participants exhibited symptoms of substance-induced mood disorder and 29.62% had substance-induced psychosis.

Although data about the prevalence of the disorder in men and women is lacking, scientists believe the difference is not that significant. A paper from Gender Medicine showed women could be more likely to develop symptoms of psychosis, but more research is necessary.

What are the causes of substance-induced psychotic disorder?

The causes of substance-induced psychotic disorders are usually unknown. What we do know is that alcohol or drugs are triggers for symptoms of psychosis. Several factors contribute to the development of this disorder, and it’s highly likely their combination is the main culprit. The causes of the substance-induced psychotic disorder are listed below:

• A stroke or traumatic brain injury
• Personal history of schizophrenia
• Genetic abnormalities

1. A stroke or traumatic brain injury

A stroke occurs when something blocks the blood supply to the part of the brain or due to a rupture of the blood vessel. In either case, parts of the brain become damaged or even die. On the other hand, traumatic brain injury (TBI) results from a violent blow or jolt to the head or body.

Both stroke and traumatic brain injury can lead to symptoms of psychosis. According to a paper from Cognitive Neuropsychiatry, TBI triggers pathophysiological processes that typically lead to psychosis after a delay of one to five years. Symptoms of psychosis after stroke or TBI usually include paranoid and persecutory delusions and hallucinations. The hallucinations are auditory in most cases.

It’s not entirely clear why stroke or TBI leads to psychosis, including substance-induced psychotic disorder. In some cases, they may act as stressors that interact with underlying genetic susceptibility. At the same time, both TBI and stroke can produce structural or functional changes in sensory and other information-processing networks.

Stroke and traumatic brain injury could make a person’s brain vulnerable and more prone to psychotic symptoms caused by substance abuse. This subject requires further research.

2. Personal history of schizophrenia

Schizophrenia is a psychotic disorder where people interpret reality abnormally. It is indicated by hallucinations, delusions, disorganized speech or thoughts, and negative symptoms such as loss of interest and social isolation.

A person with a history of schizophrenia is more likely to develop symptoms associated with a substance-induced psychotic disorder. Keep in mind schizophrenia is a lifelong condition; it’s impossible to eliminate it. However, with medications and therapy, it’s possible to manage symptoms and improve quality of life. In other words, patients can control their symptoms. Since they are still vulnerable to symptoms of psychosis, substance abuse can trigger the episodes again.

The relationship between substance abuse and schizophrenia could be a two-way street. Evidence shows drug abuse could contribute to the development of schizophrenia.

3. Genetic abnormalities

Genetic abnormalities are conditions resulting from changes to the genes or chromosomes. Mutations and variations to genes are passed to children from parents. This explains why symptoms of psychotic disorders tend to run in families.

Mutations of several genes increase a person’s vulnerability to psychosis. Evidence also shows that chromosomal abnormalities contribute to the development of mood and psychotic disorders.

While heredity is one of the causes of this disorder, it doesn’t act alone. Instead, a combination of genetics and other factors is likely the main reason someone develops the substance-induced psychotic disorder.

What are the symptoms of substance-induced psychotic disorder?

Symptoms of the substance-induced psychotic disorder are comparable to positive symptoms of other psychotic disorders such as schizophrenia. An affected person doesn’t usually know what they believe, hear, or see isn’t real. The duration of symptoms depends on the type of the substance, but it’s generally under a month. They tend to go away after withdrawal. Symptoms of the substance-induced psychotic disorder are listed below:

• Hallucinations
• Delusions
• Paranoia

1. Hallucinations

Hallucinations are defined as false perceptions of events or objects involving a person’s senses. They may seem real, but they’re not. These false sensory experiences usually occur due to chemical reactions or abnormalities in the brain. Hallucinations in substance-induced psychotic disorder can involve one or several senses. All senses can be a subject of hallucination, but people usually have auditory (hearing) and visual hallucinations. In other words, they hear or see things that aren’t there.

Physical effects of hallucinations include problems with vision, lack of personal hygiene and self-care, weight gain, and problems associated with excess weight. On the other hand, behavioral effects of hallucinations include bizarre or odd behaviors, social isolation, anxiousness, and problems keeping up with work or school, which can lead to frustration and irritability.

2. Delusions

Delusions are false beliefs that are persistent, fixed, and contradictory to reality. A person with delusions firmly believes in something despite no evidence that would confirm so. For example, they may be convinced everyone wants to harm them even though it’s not true.

There are different types of delusions, including grandiose i.e., beliefs of being superior to others.

In people with this disorder, drugs and alcohol act on the brain, which can impair its functioning and cause delusions.

Physical effects of delusions include nausea, weight gain, a higher risk of diabetes, cancer, sexual dysfunctions, poor oral health, and respiratory-related concerns. When it comes to behavioral effects, delusions cause unusual attitudes and behaviors, anxiety, tension, social isolation, and angry attitudes toward friends, family, or coworkers.

3. Paranoia

Paranoia is defined as thinking or feeling of being threatened in some way, even when there’s no evidence for it. People with paranoia often believe someone wants to harm them or is out there to get them. Paranoid thoughts can become delusions when they become so persistent that nothing can convince a person that what they think isn’t true.

Physical effects of paranoia include lack of sleep and self-care, which leads to stress, messy appearance, weight gain, and other problems associated with it. Behavioral effects of paranoia include hypervigilance (constantly looking for threats), defensiveness, accusatory behavior, inability to take criticism, aggressiveness, and social isolation.

Who is affected by substance-induced psychotic disorder?

People who misuse drugs and alcohol are affected by substance-induced psychotic disorder. The disorder may also affect people who have suffered a traumatic brain injury or who have already been diagnosed with other mental illnesses such as bipolar disorder. Persons with a family history of psychotic disorders may also be more affected by substance-induced psychotic disorders.

What are the Risk factors for substance-induced psychotic disorder?

Risk factors for substance-induced psychotic disorder are different cases that make a person more susceptible to this mental illness. Everyone who drinks too much alcohol, misuses drugs and develops drug abuse problems can develop a substance-induced psychotic disorder, but many of them do not. For that reason, it’s useful to know the factors that increase one’s susceptibility to this mental health problem. Risk factors for substance-induced psychotic disorder are listed below:

• Drinking excessive amounts of alcohol
• Drug abuse, especially polydrug use (taking multiple substances)
• Family history of schizophrenia and other psychotic disorders, mood disorders
• Alzheimer’s disease and other forms of dementia
• Personal history of mental illnesses
• Taking certain prescription medications such as methamphetamine prescribed for ADHD, opioids prescribed for pain relief, barbiturates that treat insomnia and seizures, and methylphenidate prescribed for the treatment of narcolepsy and ADHD
• Previous psychiatric hospitalization
• Non-drug related hallucinations

How is substance-induced psychotic disorder diagnosed?

The substance-induced psychotic disorder is diagnosed after a thorough evaluation. Based on the substance abuse and symptoms described, a psychiatrist will suspect the substance-induced psychotic disorder as the culprit.

To rule out other mental conditions, they will perform a psychiatric evaluation of symptoms, moods, behaviors, personal and family history, and severity of drug abuse, among others. The psychiatrist will also interview family members to get a closer insight into the patient’s condition.

For an accurate diagnosis, the psychiatrist will use DSM-5 diagnostic criteria. They will diagnose substance-induced psychotic disorder if the symptoms begin within a month of using or withdrawing from drugs or alcohol and if a patient has had no psychosis-related symptoms before drug abuse.

People may also need a physical exam and blood/urine and imaging tests such as MRI to rule out physical causes of their symptoms. In many cases, that isn’t necessary since psychosis in this disorder is associated with drug abuse.

How to prevent substance-induced psychotic disorder?

Preventing substance-induced psychotic disorder requires not taking drugs in the first place. By avoiding drugs (or excessive and chronic use of alcohol), a person doesn’t experience mind-altering effects, which could trigger symptoms of psychosis.

Prioritizing self-care is important as well, especially in people who already misuse drugs and want to reduce the risk or frequency of psychotic symptoms. Self-care comes in many forms, such as mindfulness for stress reduction, breathing exercises, connecting with friends and family, and getting educated about the disorder.

What are the treatments for substance-induced psychotic disorder?

Treatments for substance-induced psychotic disorder depend on the specific needs of each patient, the type of substance used, the presence of underlying mental health problems, and the severity of symptoms. Sometimes, it’s enough to monitor a patient in a safe environment. Substances such as cocaine exhibit stronger effects on the brain, which leads to more severe symptoms and requires more intensive treatment. Ideally, treatment for substance-induced psychotic disorder should be performed immediately to reduce the need for hospitalization due to psychotic episodes. Treatments for the substance-induced psychotic disorder are listed below:

• Medications: a healthcare professional may prescribe medications to decrease symptoms of the disorder and stabilize a patient’s mood. The medications may include benzodiazepines, antipsychotics, and selective serotonin reuptake inhibitors (SSRIs).
• Medically-supervised detox: people with addiction to alcohol or other substances need a detox supervised by a medical team. During the detox process, they may receive some medications that reduce the intensity of withdrawal symptoms and psychosis. The best results occur when a patient follows a complete rehabilitation program, whether it’s inpatient or outpatient.
• Psychotherapy: important for long-term benefits, especially in people with underlying mental health conditions. Various types of therapy are available, but the therapist chooses the one most suitable for the patient’s symptoms. Good examples are cognitive-behavioral therapy (DBT) and dialectical behavior therapy (DBT). The main role of CBT, as the most common approach, is to help patients identify negative thought patterns and replace them with more positive alternatives. During CBT sessions, patients also learn to cope with their condition, improve skills necessary for daily functioning, and manage other mental health problems they may have. The exact number of sessions varies from one patient to another, but it could be 6 to 20 for most people.

Do substance-induced psychotic disorder have a cure?

Yes, substance-induced psychotic disorders do have a cure, and that is to stop abusing any drug or alcohol. The reason is simple, alcohol or drug abuse is the main trigger for symptoms of psychosis in these cases. So, ceasing substance abuse allows a person to eliminate the main trigger behind their symptoms.

However, doing so is easier said than done in practice. Addiction is a complicated disease, and it’s not that easy for a person to simply stop using some substance. When psychosis occurs during withdrawal, it can be difficult for someone to handle. In fact, withdrawal symptoms are a major reason many people continue using drugs. However, with a well-structured treatment program, medical supervision, and support, it’s possible to overcome withdrawal and start the recovery process.