Introduction
In the drug rehabilitation context, patients often present with a particular substance use disorder and a comorbid mental disorder. Some of the comorbidities include mood disorders such as bipolar, major depressive disorder, anxiety disorders, personality disorders such as borderline personality disorder, antisocial personality disorder and trauma-related disorders such as PTSD. However, perhaps the most common comorbid mental disorder that is seen at drug rehabilitation centres is substance induced psychosis which may be generally characterised by a loss of touch or sense of reality. Some of the drugs or psychoactive substances that may trigger a psychotic episode include alcohol, cannabis, crystal meth (methamphetamine) and cocaine. This article will provide information on substance induced psychosis as it presents in the drug rehabilitation setting.
Definition and Symptoms of Psychosis
As mentioned in the introduction, psychosis may be generally defined as a loss of touch or sense of reality, therefore, substance induced psychosis is a loss of touch from reality triggered or induced by the use of a psychoactive substances. The majority of people only begin to recognise a psychotic episode when a person presents with the hallmark or telltale symptoms of the disorder which are delusions and hallucinations. Delusions are fixed ideas that persist despite evidence proving this idea to be false, the most common types of delusions that occurs in the drug rehabilitation setting include persecutory delusions where a person believes that someone or something is after them. Also, referential delusions, colloquially referred to as paranoia, consists of the belief that certain gestures, environmental cues, and comments are directed to oneself, this mainly occurs as a result of amphetamine-type use disorders. Hallucinations are perceptions that occur without any external stimulus, these can include hearing voices this is referred to as auditory hallucinations or seeing things that others do not which is referred to as visual hallucinations, lastly, tactile hallucinations involve feelings such as insects crawling in or underneath the skin. These hallmark or recognisable symptoms are also accompanied by other less noticeable symptoms namely disorganised thinking and abnormal motor behaviour. These accompanying symptoms may be observed and identified during a clinical interview conducted by a healthcare professional such as medical practitioners, psychiatrists, or clinical psychologists.
Disorganised thinking can be observed through the manner by which a patient is speaking, it consists of answering questions in a vague or irrelevant way (tangentiality) and switching from one topic to another unrelated topic (flight of ideas and loosening of associations). In addition, abnormal motor behaviour may be noted when a patient struggles to engage in goal-directed behaviour with the result that it adversely impacts their daily functioning.
In the Diagnostic and Statistical Manual, fifth edition, text-revision (DSM-5-TR), for a patient to be diagnosed with substance induced psychosis they must meet the follow criteria; “there must be a presence of hallucinations or delusions or both, there must be history from a physical examination or laboratory findings that the hallmark symptoms occurred during or soon after the ingestion, withdrawal, or exposure to a psychoactive substance, the psychoactive substance that is ingested must be capable of producing these symptoms, the disturbance is not better explained by another psychotic disorder, the disturbance must not occur exclusively during the course of a delirium, and the psychotic episode must cause clinically significant distress in social, occupational, educational, and other important areas of functioning.”
It must also be mentioned that prior to the occurrence of hallucinations, delusions, disorganised thinking, and abnormal behaviour, psychosis also has a prodromal phase or a stage where the early signs or symptoms of psychosis are present. This phase usually occurs before admission to a mental healthcare facility, or a drug rehabilitation centre, thus it is perhaps important to educate the general public on these symptoms to enable them to be able to identify an individual who might require psychiatric assistance. The prodromal phase of psychosis may last a few weeks to several years and it is characterised by signs or symptoms such as isolation or withdrawal from friends and family, a decline in self-care or hygiene, trouble concentrating or thinking clearly, a sudden decline in job or school performance, and decreased or intense emotions. Because these signs occur before the hallmark symptoms, it is during this period that early interventions may prevent the psychotic episode from persisting.
Treatment and Management
Broadly, treatment interventions for substance induced psychosis consists of psychotherapy, psychopharmacology, and social support. Psychotherapeutic interventions involve psychoeducation to improve adherence to medication and to increase the patient’s insight, family therapy to bolster and improve social support, and modality-specific treatment goals that are mainly aimed at resolving any accompanying issues or problems that might either precipitate or perpetuate the psychotic episode. While psychopharmacological treatments may not always be necessary, sometimes it may be prudent to manage the aggressive and disruptive behaviour with the relevant antipsychotic medication. Importantly, the combination of psychotherapy and psychopharmacology is more likely to improve the effectiveness of treatment outcomes. Furthermore, social workers are also important for the monitoring of patients subsequent to their discharge, this is essential to ensure that the patient does not relapse which might result in the reoccurrence of substance induced psychosis. This is also the reason that aftercare programs and support groups such as Alcoholics Anonymous, Narcotics Anonymous and Cocaine Anonymous are important in the ongoing maintenance process.