Substance or Medication Induced Psychotic Disorder DSM-5 (Alcohol-292.1, Drugs-292.9)

Substance or Medication Induced Psychotic Disorder DSM-5 (Alcohol-292.1, Drugs-292.9)

DSM-5 Category: Schizophrenia Spectrum and Other Psychotic Disorders

Introduction 

A variety of ICD-10-CM sub-codes exist, depending on the involved substance, as well as the extent to which the patient has used the substance (mild, moderate or severe). Specific sub-codes are provided for the following substances:

  • Cannabis
  • Phencyclidine
  • Other hallucinogens
  • Inhalants
  • Sedative, hypnotics or anxiolytic
  • Amphetamine (or other stimulants)
  • Cocaine
  • Other (or unknown) substance (American Psychiatric Association, 2013).

Many drugs, illicit and prescribed, can cause profound mental health problems. When in the present of a pre-existing mental health condition, the symptoms of that illness can be exacerbated. Further to that, when some substances are consumed for long periods of time, they can manifest themselves as psychotic symptoms that may present as schizophrenia and bipolar disorder. In general, psychosis is considered to be an illness that is accompanied by delusions and/or hallucinations. In most cases, such hallucinations are present outside of the patient’s scope of cognition and understanding. Hallucinations of this origin are typically visual, and may be enhanced when psychedelic drugs are used. Delusions are shifts in the patient’s reality, such that they believe that something far from reality is taking place (DualDiagnosis 2014).

Symptoms of Substance/Medication-Induced Psychotic Disorder

In many cases, an alcoholic or drug user may experience mental illness prior to ever beginning substance abuse. This may confound the easy detection of symptoms that are due to the substance itself. In most cases, if the symptoms preceded the substance use, abstinence from the substance will lead to a continuation of symptoms. In the case of substance-induced psychosis, though, the effects typically subside after the drug wears off. Nonetheless, this is not always the case, especially if the substance use was frequent and prolonged. In this circumstance, the impact could last for years after the substance use ceases (DualDiagnosis 2014).

Specific symptoms that may accompany substance/medication-induced psychotic disorder include the following:

  • Abnormal psychomotor behavior
  • Negative symptoms
  • Impaired cognition
  • Depression
  • Mania
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Diagnostic Criteria
  • At least one of the following:
  • Delusions
  • Hallucinations

There is evidence from the medical history, physical examination or lab findings of both:

  • The symptoms observed in Criteria A developed during or soon after substance use or withdrawal
  • The involved substance is capable of producing the symptoms in criteria A
  • The disturbance in not better explained by a psychotic disorder that is not substance-induced;
  • The disturbance does not occur exclusively during the course of a delirium;
  • The disturbance causes clinically significant distress or impairment in important areas of functioning (American Psychiatric Association, 2013).

The essential features of substance/medication-induced psychotic disorder are tell-tale delusions and/or hallucinations that are thought to be the result of the physiological effects of a substance or medication. Because of this requirement, there must be evidence from the history, physical examination or laboratory findings of substance use (American Psychiatric Association, 2013).

Differential Diagnosis

If actual substance intoxication or withdrawal is suspected, special diagnostic care is needed. In the case where individuals are actually intoxicated or withdrawing from alcohol or sedatives, they may experience altered perceptions that they are able to recognize as drug effects. If the individual recognizes these altered states, and does not act on the perception, than the diagnosis is not substance/medication-induced psychotic disorder. Instead, the proper diagnosis would be substance intoxication or substance withdrawal. Substance/medication-induced psychotic disorder is also not a proper diagnosis for people suffering from hallucinogenic flashbacks or alcohol withdrawal delirium (American Psychiatric Association, 2013).

Prevalence

The prevalence of substance/medication-induced psychotic disorder in the general population is unknown. Nonetheless, according to DSM-5, somewhere between 7% to 25% of patients presenting with an initial episode of psychosis in various settings are reported to have substance/medication-induced psychotic disorder (American Psychiatric Association, 2013).

One observational study evaluated 27 patients admitted to an emergency room with the diagnosis of substance-induced disorder. The diagnosis of the disorder was made on the basis of DSM IV. Of all of the patients examined, about 30% presented with substance induced psychosis, 29% tested positive for amphetamine, 43% for marijuana, 14% for cocaine, while another 14% tested negative for all substances. The investigators concluded from this investigation that substance-induced psychosis is more likely to be caused by marijuana, amphetamine and cocaine than alcohol (Aldandashi & Blackman 2009).

The lifetime prevalence of alcohol-induced psychosis (AIP) was 0.41%. Nearly all of the reported subjects were male, with the highest prevalence reported in the age group of 45-54 years (average age of 46.3 years). After adjustments were made for age and gender, the odds of ever contracting AIP was significantly higher in patients that were never married, widowed or divorced, retired or unemployed. Further to that, higher incidences were reported in middle- to low-income groups (Perala, et al 2010).

Functional Consequences

In many cases, substance or medication-induced psychosis can be severely disabling and is most often observed in the emergency room setting since it usually manifests as an acute emergency. Nonetheless, the disability is usually self-limited, and resolves at which time the offending agent is removed from their system (American Psychiatric Association, 2013).

Treatment for Substance/Medication-Induced Psychotic Disorder

The first step in treating substance/medication-induced psychosis is to remove the substance, typically under careful medical observation in order to safely control withdrawal symptoms. In most cases, the psychosis, should be relieved by removing the offensive substance. If not, the diagnosis should be changed to primary psychosis (Psychnet-UK 2014).

For the treatment of delusions, cognitive-behavioral therapy may be useful. The basis for this treatment should be persistent, gentle conversations regarding their delusional beliefs. The discussion of all available evidence to the contrary of their delusions may help to resolve their condition (Psychnet-UK 2014).

Supportive therapy and drug counselling maybe helpful, after the psychosis has resolved, to prevent recurrence and enhance overall general health (Psychnet-UK 2014).

In a recently published study, substance dependent patients living with a family member were randomly assigned to two different treatment groups: Behavioral Family Counselling (BFC) in addition to Individual-Based Treatment (IBT) or IBT, only. Patients were evaluated at baseline, after the completion of therapy, and at 3- and 6-month follow-up visits. Their results indicated that patients receiving BFD remained in treatment significantly longer than IBT patients and improved significantly from baseline on all outcome measurements relative to IBT patients. In summary, the investigators concluded that BFC is a promising method for managing patients with substance abuse issues; retaining them in treatment longer, increasing abstinence rates and reducing substance use.

References

Aldandashi, S. & Blackman, M. (2009). P01-15 The prevalence of substance induced psychosis & substance induced mood disorders in adolescent population. European Psychiatry, 24 (suppl) 1, S403.

American Psychiatric Association. 2013. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

DualDiagnosis.org (2014). What is drug-induced psychosis? dualdiagnosis.org. Retrieved 24 February 2014 from http://www.dualdiagnosis.org/drug-addiction/psychosis/

Perala, J., Kuoppasalmi, K., Pirkola, S., Harkanen, T., Saarni, S., Tuulio-Henriksson, A., et al 2010. Alcohol-induced psychotic disorder and delirium in the general population. The British Journal of Psychiatry, 197, 200-206. doi: 10.1192/bjp.bp.109.070797

PsychNet-UK (2014). Substance-Induced Psychotic Disorder. PsychNet-UK.com. Retrieved 24 February 2014 from http://www.psychnet-uk.com/x_new_site/DSM_IV/substance_induced_psychosis.html


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