Substance- or medication-induced psychotic disorder is characterized by hallucinations and/or delusions due to the direct effects of a substance or withdrawal from a substance in the absence of delirium.
People having an episode of substance-induced psychosis commonly present in emergency departments and crisis centers. There are many precipitating substances, including alcohol, amphetamines, cannabis, cocaine, hallucinogens, opioids, phencyclidine (PCP), and sedative/hypnotics. To be considered substance-induced psychosis, the hallucinations and delusions should be in excess of those that typically accompany simple substance intoxication or withdrawal, although the patient may also be intoxicated or withdrawing (1, 2). (See table Causes of Substance-/Medication-Induced Psychotic Disorders.)
Symptoms are often brief, resolving shortly after the causative drug is cleared, but psychosis triggered by amphetamines, cocaine, or PCP may persist for many weeks. Because some young people with prodromal or early-stage schizophrenia use substances that can induce psychosis, it is important to obtain a thorough history, particularly to seek evidence of prior mental symptoms before concluding that acute psychosis is due solely to substance use.Symptoms are often brief, resolving shortly after the causative drug is cleared, but psychosis triggered by amphetamines, cocaine, or PCP may persist for many weeks. Because some young people with prodromal or early-stage schizophrenia use substances that can induce psychosis, it is important to obtain a thorough history, particularly to seek evidence of prior mental symptoms before concluding that acute psychosis is due solely to substance use.
Causes of Substance- or Medication-Induced Psychotic Disorder
Medications (Iatrogenic) |
Analgesics, especially nonsteroidal anti-inflammatory drugs Anesthetics Antidepressants Anticholinergic agents Anticonvulsants Antihistamines Antihypertensives Antimicrobial medications, including fluoroquinolones, trimethoprim-sulfamethoxazole, beta-lactams, macrolides, nitrofurantoin, isoniazid, and antimalarialsAntimicrobial medications, including fluoroquinolones, trimethoprim-sulfamethoxazole, beta-lactams, macrolides, nitrofurantoin, isoniazid, and antimalarials Antiparkinsonian medications Benzodiazepines Chemotherapeutic agents including cyclosporine and procarbazineChemotherapeutic agents including cyclosporine and procarbazine DisulfiramDisulfiram Glucocorticoids Gastrointestinal prokinetic medications Hypnotics (nonbenzodiazepine) IsoniazidIsoniazid Muscle relaxants Corticosteroids Vasoconstrictors, including phenylephrine and pseudoephedrineVasoconstrictors, including phenylephrine and pseudoephedrine |
Drugs Associated With Substance Use Disorders |
Alcohol Amphetamines Benzodiazepines and hypnotics, including flunitrazepam (Rohypnol) Cannabis and cannabinoids CocaineCocaine Hallucinogens, including lysergic acid diethylamide (LSD) Inhaled nitrites Methylenedioxy-methylamphetamine (MDMA or ecstasy) Phencyclidine (PCP) |
Toxins |
Arsenic Carbon dioxide Carbon monoxide Cholinesterase inhibitors (anticholinesterase) Lead Mercury Nerve gases, including sarin Organophosphate insecticides Volatile hydrocarbons, including those from petroleum products or paint |
References
1. Keshavan MS, Kaneko Y. Secondary psychoses: an update. World Psychiatry. 2013 Feb;12(1):4-15. doi: 10.1002/wps.20001
2. Lieberman JA, First MB. Psychotic Disorders. N Engl J Med. 2018 19;379(3):270-280. doi: 10.1056/NEJMra1801490
Treatment
Discontinuation of the responsible medication or substance
A calm environment
Often a benzodiazepine or antipsychotic
In most substance-induced psychoses, discontinuing the substance and giving an anxiolytic (eg, a benzodiazepine) or antipsychotic medication is effective.
For psychosis due to dopamine-stimulating drugs such as amphetamine, an antipsychotic medication is most effective.For psychosis due to dopamine-stimulating drugs such as amphetamine, an antipsychotic medication is most effective.
For psychosis due to medications such as lysergic acid diethylamide (LSD), quiet observation may be all that is needed.
For substances with actions that do not involve dopaminergic mechanisms, observation may be all that is needed, or an anxiolytic may help (1).
Reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision, DSM-5-TR (DSM-5-TR). American Psychiatric Association Publishing, Washington, DC, 2022, 127-132.
Drugs Mentioned In This Article
