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Alcohol-Related Psychosis Clinical Presentation

  • Author: Zhongshu Yang, MD, PhD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
Updated: Dec 03, 2015


Alcohol-related psychosis can be confused with other psychiatric manifestations resulting from other substance use and/or from other medical, neurological, and psychological etiologies. The determination of cause of alcohol-related psychosis can be facilitated by thoroughly reviewing the patient’s history of clinical symptoms, course of development, and other pertinent information such as family genealogy.

The Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) provides criteria for the diagnosis of substance-induced psychotic disorder and should be helpful in clarifying etiology.[16]

Developmental history

Developmental history is useful for gathering information on in-utero exposure to medication, drugs, alcohol, pathogens, and trauma. As children, patients may have shown prodromal symptoms of a psychotic disorder, such as social isolation, deteriorating school performance, mood lability, amotivation, avolition, and anhedonia.

Development suggestive of alcohol-related psychosis involves delinquency, truancy, educational failure, early use of drugs and alcohol, and oppositional or conduct disorder.

Psychiatric history

Determine whether a psychiatric disorder or symptoms ever occurred when patients were not exposed to alcohol.

Determine whether patients ever had a psychiatric disorder or similar symptoms related to any other drug or medication.

Recent history

The patient's history of alcohol abuse is extremely significant and is determined by the following questions:

  • Is the patient currently intoxicated?
  • Is the patient at risk for withdrawal?
  • Is the patient in withdrawal?
  • Is the patient homeless?
  • Was the patient outside in the cold?
  • Did the patient fall unconscious?
  • Is the psychosis manifesting as visual, auditory, and/or tactile hallucinations?
  • When was the patient's last drink?
  • How long has the patient been drinking during the most recent episode?
  • When did the patient first start to drink?
  • How often does the patient drink?
  • How much does the patient drink?
  • Has the patient ever gone through withdrawal, and if so, how many episodes?
  • Has the patient ever had withdrawal seizures?
  • Has the patient ever had withdrawal delirium tremens?

Substance abuse history

Potentially abused substances include amphetamines, cocaine, piperidines (eg, phencyclidine [PCP], ketamine ), phenylethylamines (eg, 3,4-methylenedioxymethamphetamine [MDMA] or ecstasy/XTC), ergot alkaloids (eg, lysergic acid diethylamide or [LSD]), cannabis, over-the-counter (OTC) sympathomimetics (eg, dextromethorphan [DXM]), steroids, L-dopa, nonalcohol sedative hypnotics (eg, benzodiazepams).

Family history (including substance abuse, alcoholism, and mental illness)

Family history of psychotic disorders in the absence of alcohol suggests a primary psychiatric disorder. If no family history of psychiatric disorders is present, a diagnosis of alcohol-related psychosis can be supported.

Family history of alcoholism increase the risk of alcoholism to 3- to 4-fold.[17]

DSM-5 criteria for substance-induced psychotic disorder

Prominent hallucinations or delusions are present. Hallucinations are false sensations. In this case, they are often visual, but can also be tactile or auditory hallucinations or illusions. Delusions are false ideas. Paranoia and occasionally grandiosity may be the delusions engaged here.

Evidence from the history, physical examination, or laboratory findings indicates both (1) the hallucinations or delusions developed during or soon after (eg, within a month of) substance intoxication or withdrawal or (2) substance used is etiologically related to the disturbance.

The disturbance is not better accounted for by a psychotic disorder that is not substance-induced. Evidence that the symptoms are better accounted for by a psychotic disorder that is not substance-induced might (1) the symptoms precede the onset of the substance use, (2) the symptoms persist for a substantial period (eg, a month) after cessation of acute withdrawal or severe intoxication, or (3) the symptoms are substantially in excess of what would be expected given the type or amount of the substance use or the duration of use.

Other evidence suggests the existence of an independent non–substance-induced psychotic disorder (eg, a history of recurrent non–substance-related episodes).

The disturbance does not occur exclusively during the course of a delirium.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: When making a DSM-5 diagnosis of substance-induced psychotic disorder, specify the following:

  • Onset of psychosis in relation to substance use either (1) with onset during intoxication or (2) with onset during withdrawal
  • As an option, one can also specify current severity (in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe), which quantitatively assesses the primary symptoms of psychosis, including delusions, hallucinations, abnormal psychomotor behavior, and negative symptoms. [16]


During the initial examination of every psychiatric patient, a full physical and neurological examination is required. When a patient presents as psychotic or intoxicated, also assess the risk of dangerous behavior.


The first step in evaluating an intoxicated patient is the initial assessment for medical stability (eg, alertness, breathing, circulation), including vital signs, blood pressure, pulse, and temperature.

This is followed by an assessment for physical signs of a variety of medical complications of alcoholism (eg, blood dyscrasias, liver failure, cardiomyopathy, gastric tumors, injuries from falls). A comprehensive laboratory evaluation can assist in diagnosing medical complications.


Head injury may have occurred from a fall, altering the neurological status of the individual.

Other complications, such as peripheral neuropathy, amnesia, ataxia, and ophthalmoplegia, also can be evaluated.

Mental status

Evaluation of the mental status should focus on orientation, memory, signs of delirium, hallucinations, and delusions, as well as affect with risk of assessment for violence and suicide. Checking the mental status frequently is important, as the affect and level of consciousness may fluctuate dramatically.

A mental status examination may appear as follows for intoxication with psychosis:

  • General appearance and behavior: Disheveled, withdrawn, malodorous, strong alcohol smell breath, poor eye contact, difficult to engage, actively responding to internal stimuli
  • Psychomotor agitation
  • Speech: Low volume, slurred
  • Thought processes: Disorganized
  • Thought content: Auditory hallucinations, reports suicidal ideation, denied homicidal ideation
  • Mood: Irritable
  • Affect: Irritable to flat
  • Insight: Poor
  • Judgment: Poor
  • Somnolence and disoriented to person place and purpose
  • Abstractions intact

Mental status examination for alcohol withdrawal and psychosis may appear as follows:

  • General appearance and behavior: Disheveled, agitated, confused, difficult to engage, actively responding to internal stimuli by touching areas of own skin fearfully; poor eye contact
  • Psychomotor agitation
  • Speech: Normal to elevated, slightly pressured
  • Thought processes: Disorganized
  • Thought content: Tactile hallucinations, denied suicidal or homicidal ideations
  • Mood: Irritable
  • Affect: Irritable to agitated
  • Insight: Poor
  • Judgment: Poor
  • Alert and oriented to person, place, and purpose
  • Abstractions intact

Dangerous behaviors

Assess patients for the potential for assault or self-harm.



Possible causes or contributors to alcohol-related psychosis include the following:

  • Chronic alcoholism
  • Thiamine deficiency (eg, diet, starvation, emesis, gastric tumor)
  • Alcohol-dependent withdrawal early-stage (8-24 h) or late-stage (36-72 h) (monitor temperature at least every 4 h)
  • Comorbid substance abuse (therefore, do an extensive toxicology screen)
  • Lack of psychosocial supports
  • Comorbid psychotic and mood disorders

Alcoholic idiosyncratic intoxication (pathological intoxication):Impulse control disorder, advanced age, early-onset alcohol use It is important to also evaluate the use of nontraditional methods of alcohol consumption. A study of intoxication in a combat theater, where alcohol is prohibited, showed that unexplained psychosis may be the result of consumption of mouthwash. Nonprescription brands of mouthwash can contain up to 23.40% ethanol by volume.[18]

Contributor Information and Disclosures

Zhongshu Yang, MD, PhD Health Science Assistant Clinical Professor, Department of Psychiatry and Behavioral Sciences, University of California, Davis, School of Medicine; Medical Director, Crestwood Sacramento Psychiatric Health Facility

Zhongshu Yang, MD, PhD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.


Glen L Xiong, MD Associate Clinical Professor, Department of Psychiatry and Behavioral Sciences, Department of Internal Medicine, University of California, Davis, School of Medicine; Medical Director, Sacramento County Mental Health Treatment Center

Glen L Xiong, MD is a member of the following medical societies: AMDA - The Society for Post-Acute and Long-Term Care Medicine, American College of Physicians, American Psychiatric Association, Central California Psychiatric Society

Disclosure: Received royalty from Lippincott Williams & Wilkins for book editor; Received grant/research funds from National Alliance for Research in Schizophrenia and Depression for independent contractor; Received consulting fee from Blue Cross Blue Shield Association for consulting. for: Received book royalty from American Psychiatric Publishing Inc.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Additional Contributors

Jennifer S Morse, MD Associate Medical Director, Optum Health

Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.


Michael F Larson, DO Clinical Instructor, Department of Child and Adolescent Psychiatry, Harvard Medical School; Psychiatrist, Harvard Vanguard Medical Associates and Private Practice

Michael F Larson, DO is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, and American Society of Addiction Medicine

Disclosure: Nothing to disclose.

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