Substance-Induced Psychotic Disorders

Definition & Core Criteria - High on Psychosis

• Prominent delusions and/or hallucinations directly due to substance effects.
• DSM-5 Highlights:
  • Symptoms emerge during or within 1 month of intoxication/withdrawal or medication use.
  • Substance is known to cause psychosis.
  • Not better explained by a non-substance-induced psychotic disorder.
    • Consider if: symptoms predate use, persist >1 month after stopping, or history of primary psychosis.
  • Not exclusive to delirium.
  • Causes significant distress/impairment.

⭐ The temporal relationship between substance use and psychotic symptoms is paramount for diagnosis.

Common Culprit Substances - Drug‑Fueled Delusions

⭐ Stimulants (amphetamine, cocaine) and cannabis are very common precipitants of substance-induced psychosis.

Various substances can induce psychosis, typically during acute intoxication or withdrawal phases:

📌 C-STASH: Cannabis, Stimulants, Toxidromes (e.g., PCP), Alcohol, Sedatives/Hypnotics, Hallucinogens (e.g., LSD).

Clinical Picture & Red Flags - Is it the Drug Talking?

• Key Symptoms:
  • Hallucinations (often visual, tactile), delusions.
  • Disorganized speech/behavior.
• Onset & Course:
  • Rapid onset, linked to substance intoxication/withdrawal.
  • Transient: Resolves typically within days to weeks (max 1 month) after substance cessation.
• Differentiation Clues (vs. Primary Psychosis): 📌 T.O.A.S.T.
  • Timing: Symptoms appear/disappear with substance use/cessation.
  • Other signs: Intoxication/withdrawal symptoms present.
  • Age of onset: Can be atypical for primary disorders.
  • Sensory: Visual/tactile hallucinations more common.
  • Typically no long prodrome or strong family history of primary psychosis.

⭐ Visual and tactile hallucinations are more common in substance-induced psychosis compared to auditory hallucinations typical of schizophrenia.

Diagnosis & Management - Detox & De‑escalate

• Diagnostic Approach:
  • History: Detailed substance use (type, dose, frequency, last use).
  • Examination: Comprehensive physical and mental status assessment.
  • Investigations: Urine toxicology screen; rule out other medical conditions and primary psychotic disorders.
• Acute Management: 📌 SAFE Approach: Safety, Agitation control, Fluids/Food, Environment.

*   Key: Identify & stop causative agent. Provide calm, safe environment.
*   Benzodiazepines for withdrawal (e.g., alcohol, sedatives) or severe agitation.
*   Antipsychotics (e.g., Haloperidol, Olanzapine) for prominent psychosis: **short-term** use.

⭐ The primary treatment is cessation of the offending substance and supportive care; antipsychotics are adjunctive and short-term.

High‑Yield Points - ⚡ Biggest Takeaways

• Common triggers: Alcohol, cannabis, stimulants (cocaine, amphetamines), hallucinogens (LSD, PCP).
• Timing: Psychosis onset during or soon after substance intoxication or withdrawal.
• Key features: Predominantly hallucinations (auditory/visual) and/or delusions.
• Differential: Symptoms are not better explained by a non-substance-induced psychotic disorder.
• Prognosis: Symptoms typically resolve within 1 month post-substance cessation.
• Management: Stop offending agent; supportive care; short-term antipsychotics for severe cases.
• Severity: Psychotic symptoms are in excess of typical intoxication/withdrawal effects.