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Alcohol-Related Psychosis Treatment & Management

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

Medical Care

Because most cases of alcohol-related psychosis are self-limiting, removal of alcohol should suffice.

The initial treatment of patients with alcohol intoxication or withdrawal should focus on medically stabilizing the patient by assessing respiratory, circulatory, and neurological systems. An intoxicated patient or one undergoing withdrawal to the point with psychosis should be considered a medical emergency because of the risks of unconsciousness, seizures, and delirium. Medical treatment should focus on the effect of alcohol on the body as a whole. A patient with head trauma may be misdiagnosed with Wernicke-Korsakoff syndrome, and a neurologic examination should always be considered. Alcohol withdrawal requires inpatient hospitalization for more than 72 hours after the risk of delirium tremens has subsided.

Alcohol withdrawal psychosis is a symptom of alcohol withdrawal and should be treated in the context of alcohol withdrawal. Treatment is initiated with cautious use of oral or intramuscular benzodiazepines. Lorazepam (Ativan) at 1-2 mg or chlordiazepoxide (Librium) at 25-50 mg PO or IM is used commonly and frequently under the guidance of Clinical Institute Withdrawal Assessment (CIWA) of Alcohol Scale. The dose of benzodiazepine is tapered over the next 5-7 days.

In the event patients are in danger of harming themselves or others, rapid sedation should be initiated with a high-potency antipsychotic drug such as haloperidol (Haldol) at 5-10 mg PO or IM, frequently given with anticholinergics, benztropine (Cogentin) (1-2 mg) or diphenhydramine (Benadryl) (25-50 mg); both can be given PO or IM to prevent extrapyramidal adverse effects.

Antipsychotics may lower the seizure threshold and should not be used to treat withdrawal symptoms unless absolutely necessary and used in combination with a benzodiazepine or antiseizure medications (eg, valproic acid [Depakote] or carbamazepine [Tegretol]).

Nonmedical treatment includes the use of mechanical wrist and leg restraints if acute danger of assault or self-harm is not managed adequately by chemical restraints alone.

Treatment may include thiamine at 100 mg parentally followed by supplemental thiamine at 100 mg 3 times a day, folic acid at 1 mg, and a daily multivitamin.

In case of a suspected opiate overdose, administer naloxone (Narcan) at 0.4-2 mg IV, IM, SC, or endotracheally.

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Consultations

Neurologist consultation can assist in the evaluation of the patient's neurological status to rule out neurological consequences of alcohol (ie, peripheral neuropathy, Wernicke-Korsakoff syndrome, seizures, postictal states, encephalitis, subdural hematoma).

An internal medicine specialist can provide extended care to patients with a blood dyscrasia, electrolyte abnormality, thiamine deficiency, gastric tumors, or diabetes.

Psychiatrist and social services counselor can assist with inpatient treatment for substance abuse or further psychiatric stabilization.[19]

The patient and family need education about alcohol and referral to Alcoholics Anonymous (AA) and family supports. Social services personnel can help with outpatient services (eg, AA, sober houses, provider appointments). Family issues may be involved, and social services counselors can be helpful in providing supportive and directive care.

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Diet

No specific dietary restrictions are necessary. However, if a patient has a thiamine-poor diet, further dietary intake should be normalized.

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Activity

A patient intoxicated with alcohol or with severe alcohol withdrawal symptoms frequently has ataxia and can with waxing and waning sensorium and consequently are at risk for falls. Limit the activity of such patients until symptoms have resolved.

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Acknowledgements

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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