In relation to Substance induced disorder, DSM-4 had come under scrutiny whereby its strengths like reliability and validity of dependence were assessed along with few concerns (American Psychiatric Association, 2013). In DSM-5, these concerns were studied in details to find relevant evidence. The concerns mainly referred to retaining the two broad categories of substance induced disorder: abuse and dependence, addition or removal of further criteria and identification of the severity indicator of substance induced disorder. The DSM-5 took into account an “axial” system for grouping psychological disorders into five different classes namely, (1) all psychological diagnostic classes apart from personality disorder and mental retardation, (2) mental retardation and personality disorders, (3) environmental and psychosocial factors that contribute to the condition, (4) acute or general medical conditions, and (5) Children’s Global Assessment Scale or Global Assessment of Functioning. Furthermore, although in DSM-4, substance abuse disorder was divided into two discrete classes of substance dependence and substance abuse, the DSM-5 code combined the two into a uniform diagnostic class, commonly referred to as substance use disorder (American Psychiatric Association, 2013).
Prominent psychotic symptoms such as, delusions or hallucinations are determined to be a direct manifestation of the impacts of psychoactive substances and are the primary characteristics of substance-induced psychosis. The substance being consumed often induces a plethora of psychotic symptoms while a person is intoxicated (under the direct influence of a certain drug) or during the withdrawal phase. Diagnosis of the condition is usually done when the psychotic symptoms experienced by the person are severe and comprise of prominent symptoms (Fasihpour, Molavi & Shariat, 2013). Substance-induced psychosis usually interferes with the mental capacity of the affected person and makes it difficult to identify reality, relate with others, or communicate, thereby meddling with the capability to deal with life stresses.
1. Critical Analysis of Comprehensive Information related to Aetiology of Substance-Induced Psychosis
Psychosis and Substance Induced Psychosis:
It refers to the psychological disorder whereby an individual loses touch with reality and it adversely affects his or her cognitive functions and subsequently, behaviour.
Substance abuse primarily refers to using psychoactive substances like alcohol, cannabis or medications that leads to serious mental and physiological disorientation. Such disorientation often accounts for Psychosis. The primary symptoms leading to psychosis usually originate from the substantial use or withdrawal from amphetamines, phencyclidine, opioids, inhalants, sedatives, anxiolytics, cocaine, LSD, hallucinogens and other related drugs and substance. As discussed in ICD-10, Substance Induced Psychosis or SIP can get partially resolved within 1 month or full resolved within 6 months when proper attention is given to his or her experiences of hallucinations or delusions occurring as a result of intoxication or abstinence. Such experiences when diagnosed and treated under expert care can result in competent resolution (American Psychiatric Association, 2013).
Evidence from DSM-5 have shown that natural and synthetic cannabis are associated with psychotic disorder. Compounds of synthetic cannabis have been found to be similar to the functions of psychoactive agents like delta-9-THC. These compounds in synthetic cannabis have higher potency for causing psychosis as some of their ligands lack cannabidiol, a component with antipsychotic property found in natural cannabis. Synthetic cannabis, thus, create greater dependency in individuals which can even lead to life-threatening situations in case of overdose.
Methamphetamine: Individuals using methamphetamine have been found to suffer more from psychosis accounting for 52-100% in the population (Roncero et al., 2013). The incidence is relatively higher in young users like college students. The rate of their psychotic symptoms varies within a wide range. Evidence from further researches have also suggested that individuals who have one or more members in their family suffering from schizophrenia have a higher chance of developing methamphetamine induced psychosis
Cocaine: The speed of onset of Psychosis and its type usually depends on the type substance used. Psychotic symptoms occurring from Cocaine intoxication coupled with acute changes in abstinence causes dopaminergic changes in brain function leading to persecutory delusions such as formication (Hasin et al., 2013).
LSD: It has been heavily linked with hallucinogenic properties originating from the serotonin-2A receptor (5-HT2A), eventually leading to the emergence of psychotic symptoms. Individuals are at high risk of developing a second episode of psychotic syndrome if they resume the intake of these drugs (Hasin et al., 2016).
Alcohol: Researches have revealed comparatively lesser evidence on the correlation between alcohol abuse and psychosis. However, in case of most patients, their early stages have been found to be linked with alcohol use. The characteristics included auditory, visual or tactile hallucinations which were significant even on withdrawal (Hasin et al., 2015).
Around 20% of individuals who have previously suffered from psychosis develop Substance Induced Psychotic Disorder or SIPD owing to the overuse of substance and prescribed or non-prescribed medication such as steroid and non-steroidal anti-inflammatory drugs, antihistamines, muscle relaxants and psychotropic medications. Individuals who indulge in heavy use of substances like marijuana, psychedelics, amphetamine or cocaine are also at highest risk to develop psychosis (American Psychiatric Association, 2013). Legalisation of potent form of cannabis, overuse of multiple medications and the opioid epidemic have been cited as potent causes of SIPD. Psychosis is not exclusively related with the course of delirium. The disturbances brought about by this disorder can cause significant functional impairment in social, personal and occupational areas.
As stated in DSM-5, frequent occurrences of hallucinations or delusions are prominently visible. These hallucinations or delusions get triggered either during the use of these intoxicating substances, known to cause psychosis, or occur within or after a month the use was withdrawn (Weibell, ten Velden Hegelstad & Johannessen, 2016). Certain medical situations (such as, Huntington’s chorea and/or temporal lobe epilepsy) often result in the onset of a range of psychotic symptoms, and, since persons are expected to be consuming prescribed medications for these situations, it becomes problematic to decide the potential cause of the symptoms. Furthermore, the symptoms of substance-induced psychosis should also be distinguished from those of dementia, delirium, primary psychotic disorders, and substance withdrawal. While there is a lack of absolute means of determining and diagnosing the symptoms as a consequence of substance use, recording the patient history, careful examination of the symptom onset, its source, and substance use proves imperative in this regard. Differentiating between psychiatric disorder and substance-induced psychosis may be assisted by taking into account (i) time of symptom onset; (ii) patterns of substance abuse; (iii) symptom consistency; (iv) family history; (v) response of the patient to substance abuse treatment; and (vi) reason stated by the patient for substance abuse (Niemi-Pynttäri et al., 2013).
As mentioned previously, symptoms of psychosis are significantly severe at two specific stages: during the period of intoxication and during the period of withdrawal (American Psychiatric Association, 2013). The level of severity is assessed by observing the length of hallucinatory periods or the extent to which the delusions exist accompanied by abnormal psychomotor symptoms. The method begins with rating severity, on weekly basis, on a five-point scale then proceeds with comparing the score achieved in each week of a month to see if the treatment administered is bringing about any noticeable change. Thus, the quantitative analysis helps in addressing the progress made by a patient in succeeding months.
In the course of treatment of psychosis, early intervention is considered to be very important. This is because, the person is less susceptible to suffer for long term psychotic problems if his or her issues are attended sooner. The treatment of such substance induced psychosis aims at either reducing the disturbing effects of the disorder or eliminating them completely (American Psychiatric Association, 2013). Assessment of drug and alcohol and comprehensive care management plan outlined for patients suffering from Substance Induced Psychotic Disorder or SIPD helps in focussing on the needs of the patients.
Such intermediate treatment plans strategically identifies:
Such treatment includes pharmacotherapeutic regimens like prescribing amphetamine for Methamphetamine induced psychosis. However, the clinicians are advised to abstain from depending heavily on curative drugs like Methadone unless the situation is highly critical and demands a harm reduction plan (Karila et al., 2014). Evidences have established amphetamine as a potent CNS stimulant that produces modest improvements in working memory, cognition, attention, inhibitory control, and long-term episodic memory, when prescribed at low therapeutic doses (Pérez?Mañá et al., 2013). However, potential side effects of the drug include hypotension, hypertension, Raynaud’s phenomenon, abdominal pain, nausea, loss of appetite, and profuse sweating. Furthermore, it might also increase alertness, self-confidence, apprehension, insomnia, and mood swings. Methamphetamine contains a mixture of dextromethamphetamine and levomethamphetamine and is a strong CNS stimulant. Nonetheless, it might lead to the onset of euphoria, alterness, alteration in libido, dysphoria, grandiosity, and obsessive behaviours among the patients (McKetin et al., 2013).
Only those compounds of Benzodiazepines need to be preferably used that are long-acting because it is advisable to use this drug for a short duration. This category of psychoactive drugs most commonly act on the GABAA receptor and lead to a hypnotic, sedative, and anxiolytic effect on the affected person. However, most prevalent side effects are realted to their mucle relaxing and sedation actions. The drug can induce dizziness, drowsiness, and reduced alertness (Jones, Paulozzi & Mack, 2014). Additionally, it has also been associated with an impairment in driving skills, disinhibition and depressive disorder.
Before beginning with any prescribed pharmacological care, the clinicians need to consider all those non-prescribed medicinal drugs that the patient had been taking to reduce the side effect of the substance along with the potential interactions that the intoxicating substances might have with the administered drugs.
The non-pharmacological treatment plan essentially comprise of managing the comorbid disorders and those of substance induced with a long-term perspective. The intervention plan can become an effective therapy only when it is built on trust, respect and honesty. The mental health care practitioners are required to establish a good rapport with the patients through active listening, empathy and a constant assurance that his or her conditions would get better in the coming days.
CBT or Cogitative behavioural Therapy has also been cited as a beneficial remedy for comorbidity of mental and substance induced disorder. It is suggested that if psychosis initiates from a condition induced by long-term symptoms, then the best option is to rehabilitate the concerned patient in order to proceed with further treatment. In such rehabilitation program it is expected of the clinical staff to gather more information from the patient’s support network. As discussed in (American Psychiatric Association, 2013), only then the severity and acuity of the disorder can be appropriately understood. During rehabilitation, patients are administered with psychotherapy and cognitive behavioural therapy. Evidences with well-supported scientific bases have revealed that under proper treatment and care, the recurrence rate reduces to almost zero.
The effectiveness of a non-pharmacological treatment is also hugely dependent on the patient’s readiness to improve his or her condition. The clinician might achieve this by increasing the patient’s awareness of the negative impact of substance abuse and a forecast of how his or her life might be once hey overcome their situation (Carpenter & Tandon, 2013). The patient’s family is also involved in this Detoxification care plan.
One of the major challenges faced during the treatment of a patient suffering from psychosis is separating his or her predispositions of any other mental disorder generating delusions from those symptoms that get triggered by Substance Abuse (Townsend & Morgan, 2017). The anti-psychotic treatments administered on patients also depends on whether the bases originate from short-term or long-term, otherwise, it leads to serious and sustained and chronic impairment in psychosocial ability (Alterman, 2014). Some other challenges are encountered while recognising and increasing the awareness of the patient and the family members on high risk psychosis situations, or warning indications, and during development of novel coping skills for management of such high-risk events. Furthermore, the fat that most patient suffering from substance-induced psychosis report hallucinations, it becomes difficult to make them realise that the visions they perceive are not real. Another potential challenge is encountered while making the patients adhere to lifestyle changes for decreasing their urge for drug use and enhancing adoption of healthy activities.
Conclusion
In Conclusion, it might be stated that substance induced psychosis is a raging issue in this generation which needs to be recognised by both the family and the care groups. The occurrence of these psychotic symptoms are not always related with the predisposition of any other mental disorder such as schizophrenia, however, comorbidity of substance induced disorders and other mental disorders is common. The disturbances brought about by this disorder can cause significant functional impairment in social, personal and occupational areas.Proper remedial measures involve understanding the social and personal causes triggering this disorder through substance abuse. However, it is possible to completely overcome it by means of the above therapeutic measures.
References
Alterman, A. (2014). Substance abuse and psychopathology. Springer.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Carpenter, W. T., & Tandon, R. (2013). Psychotic disorders in DSM-5: summary of changes. Asian journal of psychiatry, 6(3), 266-268.
Fasihpour, B., Molavi, S., & Shariat, S. V. (2013). Clinical features of inpatients with methamphetamine-induced psychosis. Journal of mental health, 22(4), 341-349.
Grant, B. F., Saha, T. D., Ruan, W. J., Goldstein, R. B., Chou, S. P., Jung, J., … & Hasin, D. S. (2016). Epidemiology of DSM-5 drug use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions–III. JAMA psychiatry, 73(1), 39-47.
Hasin, D. S., Greenstein, E., Aivadyan, C., Stohl, M., Aharonovich, E., Saha, T., … & Grant, B. F. (2015). The Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (AUDADIS-5): procedural validity of substance use disorders modules through clinical re-appraisal in a general population sample. Drug and alcohol dependence, 148, 40-46.
Hasin, D. S., Kerridge, B. T., Saha, T. D., Huang, B., Pickering, R., Smith, S. M., … & Grant, B. F. (2016). Prevalence and correlates of DSM-5 cannabis use disorder, 2012-2013: findings from the National Epidemiologic Survey on Alcohol and Related Conditions–III. American Journal of Psychiatry, 173(6), 588-599.
Hasin, D. S., O’Brien, C. P., Auriacombe, M., Borges, G., Bucholz, K., Budney, A., … & Schuckit, M. (2013). DSM-5 criteria for substance use disorders: recommendations and rationale. American Journal of Psychiatry, 170(8), 834-851.
Hasin, D. S., Saha, T. D., Kerridge, B. T., Goldstein, R. B., Chou, S. P., Zhang, H., … & Huang, B. (2015). Prevalence of marijuana use disorders in the United States between 2001-2002 and 2012-2013. JAMA psychiatry, 72(12), 1235-1242.
Jones, C. M., Paulozzi, L. J., & Mack, K. A. (2014). Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths-United States, 2010. MMWR. Morbidity and mortality weekly report, 63(40), 881-885.
Karila, L., Roux, P., Rolland, B., Benyamina, A., Reynaud, M., Aubin, H. J., & Lançon, C. (2014). Acute and long-term effects of cannabis use: a review. Current pharmaceutical design, 20(25), 4112-4118.
McKetin, R., Lubman, D. I., Baker, A. L., Dawe, S., & Ali, R. L. (2013). Dose-related psychotic symptoms in chronic methamphetamine users: evidence from a prospective longitudinal study. JAMA psychiatry, 70(3), 319-324.
Niemi-Pynttäri, J. A., Sund, R., Putkonen, H., Vorma, H., Wahlbeck, K., & Pirkola, S. P. (2013). Substance-induced psychoses converting into schizophrenia: a register-based study of 18,478 Finnish inpatient cases. The Journal of clinical psychiatry, 74(1), e94-9.
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Townsend, M. C., & Morgan, K. I. (2017). Psychiatric mental health nursing: Concepts of care in evidence-based practice. FA Davis.
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