Secondary Schizophrenia (47 page)

versely, in communities where substance abuse among
psychotics is much less, earlier age of onset of psychosis in males is not observed (Venkatesh et al., in
Intoxication

press
[92]).

Psychotic symptoms can be symptoms of intoxication with several addictive substances. Each substance produces its characteristic picture. Apart from
Diagnosis and treatment

the characteristic psychotic symptoms described ear-The differentiation between a primary psychotic dis-lier, hypervigilance, euphoria, choreoathetoid move-order that co-occurs with substance use and an SIP is
ments, tachycardia, hypertension, and papillary dilata-critically important for treatment. The assessment of
tion characterize intoxication with amphetamines.

psychotic symptoms that occur during a period of sub-Psychotic agitation that rapidly shifts to intense dys-stance use requires: i) knowledge about the etiological
phoria and then to somnolence without any sedative
120

relationship between specific substances and specific
medications is characteristic of cocaine intoxication.

Chapter 8 – Substance-induced psychosis: an overview

Presence of vivid visual hallucinations, time distor-beyond the fourth decade of life should alert the
tion, and synesthesias suggest use of hallucinogens
clinician regarding the possibility of them being
and LSD. Intoxication with PCP produces a state of
secondary to substance use.

dissociation with unpredictable secondary effects,
3. Type amount of substance: Clinicians should take
including agitation, unpredictable aggressive out-into account the likelihood that the type and
bursts, and catatonic postures sometimes associated
amount of drug abused could cause psychotic
with significant autonomic arousal mimicking neu-symptoms. For instance, a small dose of cocaine is
roleptic malignant syndrome.

known to cause psychotic symptoms, whereas
opioid drugs cause psychotic reactions, only at
Withdrawal

much higher doses.

4. Symptoms: Symptoms of SIP may mimic

Withdrawal from alcohol, benzodiazepines, and other
schizophrenic symptoms quite closely. However,
sedatives produces withdrawal-related psychotic
nonauditory hallucinations, which are rare in
symptoms with or without delirium. Auditory and
schizophrenia, commonly occur with SIP.

visual hallucinations, paranoid delusions, and auto-Conversely, passivity and thought-alienation
nomic arousal associated with withdrawal from these
phenomena and formal thought disorders are rare
may mimic stimulant intoxication.

in SIP.

5. Persistence during sustained abstinence: Psychotic
Identifying SIP and primary psychosis

symptoms persisting beyond several weeks of
associated with substance abuse

sustained abstinence from substance use also
strengthen evidence for the diagnosis of primary
Identifying SIP and differentiating it from primary
psychosis. Typically, the psychotic symptoms of
psychosis can be particularly challenging. SIP is diag-SIP start decreasing in severity following
nosed when psychotic symptoms start during intoxica-abstinence even without antipsychotic
tion or withdrawal but persist beyond periods of acute
medications. If they persist at the same severity
intoxication or withdrawal for a few days or weeks. It
despite documented abstinence, then the clinician
is also diagnosed during intoxication or withdrawal if
should suspect primary psychosis and consider
the psychotic symptoms are very prominent and war-starting antipsychotics. However, the situation can
rant independent clinical attention or when they are
be confusing when the psychotic symptoms are so
clearly in excess of what may be expected in an intoxi-severe that the clinician is compelled to use
cation or withdrawal syndrome. It is of obvious impor-antipsychotics at the outset. In this situation, it
tance to learn whether heavy substance consumption
may be worthwhile to stop antipsychotics and
or psychosis started first. If there is reliable history that
observe for re-emergence of psychotic symptoms
the psychotic syndrome had started either along with
while ensuring continued abstinence.

or before heavy use of the substance, then the diagnosis is one of primary psychosis. However, typically sub-It is clear that differentiating SIP from nonSIP is a
stance abusers provide a very unreliable history; some-complex task requiring time, multiple sources of infor-times they present after several years of substance use
mation, laboratory facilities, and expertise. This may
and psychosis, which makes recall difficult and unreli-not be possible in an emergency setting or outpatient
able. The diagnosis becomes unclear if substance abuse
clinics where these patients usually present. Admis-had begun first and there was no substantial period of
sion for a few weeks facilitates repeated and thor-abstinence. The following points are helpful in arriv-ough physical and mental status examination, provides
ing at a differential diagnosis of SIP and primary psy-time for collecting information from different sources,
choses:

including family members and friends, and ensures
1. Past and family history: Past and family history of
abstinence. Many features of SIP are shared by psy-nonsubstance induced psychosis weighs the
chotic disorders due to general medical/neurological
diagnosis in favor of a primary psychosis.

disorders. Inpatient evaluation also helps to rule these
2. Age of onset: Most primary psychoses have onset
out. Alternatively, if family members and friends can
in the second and third decades of life. In persons
ensure abstinence and frequent visits, then outpatient
121

using substances, onset of psychotic symptoms
evaluation is also possible.

Organic Syndromes of Schizophrenia – Section 3

A number of research instruments have been
such patients do better in the substance abuse service
developed to assess substance use disorders and Axis
system.

1 psychiatric disorders (see Caton
et al.
for review
[93]).
These include general-purpose diagnostic in-

Risk of violence and suicide

struments: clinician-administered instruments such as
Special mention should be made about the risk of
Schedules for Clinical Assessment in Neuropsychiatry
violence and suicide among patients with substance
(SCAN), the Structured Clinical Interview for DSM-use and psychotic symptoms. Substance use and psy-IV (SCID), and the Schedule for Affective Disorders
chosis are both associated with impaired inhibition,
and Schizophrenia (SADS) that leave the differenti-of impulses, including aggressive ones. They both
ation of “primary” or “secondary” to clinical judg-independently put persons in greater risk for vio-ment; interviews designed for lay interviewers such
lence, and, not surprisingly, persons having the great-as the Composite International Diagnostic Interview
est risk of violence have dual diagnoses. The likeli-

(CIDI) or the Diagnostic Interview Schedule that rely
hood of committing a violent crime is 8–25 times
on the subject’s attribution of the etiology. Both these
higher than in mentally healthy men; this is about 2–
approaches are conducive to diagnostic unreliability as
4 times greater than those with schizophrenia with-they rely on individual judgment rather than a built-in,
out substance abuse
[94, 95].
Reports of suicide risks
systematic method of differentiation. The Psychiatric
in dually diagnosed persons are, however, conflicting.

Research Interview for Substance and Mental Disorder
Some studies report increased risk
[96]
and others
(PRISM) was developed to address this lacuna and to
decreased risk
[97]
of suicide in schizophrenia patients
provide an instrument that is suitable for comorbidity
when they have comorbid substance abuse. Although
research and designed to assess 20 Axis 1 and 2 Axis
violence and suicide risks associated with SIP per se are
II psychiatric disorders in heavy users of alcohol and
unknown, we believe that clinicians should be vigilant
other substances. The PRISM includes the following
for such risks since both psychosis and substance use
features: periods of drug/alcohol use and abstinence
themselves have greater risk of suicide than mentally
explored in detail prior to other sections of the inter-healthy individuals.

view, so that when the interviewer administers sections
on psychotic disorders, the history of drug and alcohol
use is known; interviewer instructions and guidelines
Future directions

to assist in differentiating substance-induced from pri-Co-occurrence of substance use and psychosis is an
mary symptoms and in determining the timing of the
important health problem. Although it is a challeng-psychiatric symptoms and substance use.

ing clinical situation, it gives ample opportunity to
understand the biology of both conditions. Nosolog-Treatment
ical status of SIP and the role of substances in causing
Many researchers and clinicians assert that patients
schizophrenia still remain controversial and are only
who abuse substances and develop severe mental ill-recently being clarified. The need for further research
ness require a unique set of treatment interventions
is felt in these fields because they have significant clin-apart from the traditional mental health and sub-ical and public health implications. Advancement in
stance abuse programs. It has been suggested that
neuroimaging and genetic technology hold promise
such patients do not benefit from the standard treat-in elucidating the pathophysiology of these condi-ments and that failure to address both mental health
tions. This should lead to improvement in clinical care
and substance abuse problems leads to undesirable
of these conditions and guide public health policies
outcomes. There is also a prevailing viewpoint that
regarding substances.

122

Chapter 8 – Substance-induced psychosis: an overview

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