Alcohol-Related Psychosis Clinical Presentation

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, Text Revision (DSM-5-TR) provides criteria for the diagnosis of substance/medication-induced psychotic disorder and should be helpful in clarifying etiology. ^[16]

DSM-5-TR criteria for substance/medication-induced psychotic disorder

A. Prominence of one or both of the following symptoms:

1.  Delusions - false ideas
2. Hallucinations - false sensations

B. Evidence from the history, physical examination, or laboratory findings indicates both (1) the symptoms in Criterion A developed during or soon after (eg, within a month of) substance intoxication or withdrawal and (2) the involved substance is capable of producing the symptoms in Criterion A.

C. The disturbance is not better accounted for by a psychotic disorder that is not substance/medication-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).

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

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. ^[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 defiant 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?

• How often does the patient drink?

• How much does the patient drink?

• When did the patient first start to 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?

• Has the patients ever had history of blackouts, DUIs, or other legal history from the alcohol use disorder?

• Does the patient's alcohol use disorder lead to significant occupational, social, and relational impairment?

• What is the patient's chemical dependence treatment history and longest sobriety?

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, benzodiazepine), and opiate pain medications.

Family history

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

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

Physical

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.

Neurologic

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]

Theoretically, alcohol may potentiate or initiate a psychotic disorder, such as schizophrenia, through kindling, a process where repetitive neurological insult results in greater expression of disease.

In some instances, psychosis may persist and may be considered by DSM-5-TR criteria as a substance-induced psychotic disorder.

Other complications may include increased risks for suicide, depression, and/or psychosocial impairment.