15th February 2025

Substance and alcohol-induced psychosis

Prescription drugs and illicit substances (e.g. cannabis, spice, meth, MDMA, LSD [lysergic acid diethylamide]) can cause symptoms of psychosis, but can also worsen underlying mental health conditions. Alcohol can also cause psychosis and is perhaps most dangerous during withdrawal. Delirium tremens affects approximately 5% of people in alcohol withdrawal and can be fatal.

Alcohol withdrawal

The general timeline of alcohol withdrawal is as follows:

• 6-12 hours: anxiety, shaking, nausea, headaches, sweating and insomnia
• 12-48 hours: hallucinations and seizures
• 48-72 hours: delirium tremens (hallucinations, confusion, seizures, sweating, tachycardia and hypertension)

Management of alcohol withdrawal includes CIWA (clinical institute withdrawal scale) scoring to assess severity, consideration of benzodiazepine or carbamazepine, and thiamine to prevent Wernicke’s encephalopathy.

For delirium tremens, first-line management is with oral lorazepam; second-line options include IV lorazepam or haloperidol. Ideally, the patient should be managed in the ICU in a well-lit room.

References

• Ellul M, Solomon T. Acute encephalitis – diagnosis and management. Clinical Medicine. April 2018. 18(2):155–159
• Epilepsy Foundation. Psychosis. Online [cited 28 January 2022]. Available from: https://www.epilepsy.com/learn/challenges-epilepsy/moods-and-behavior/mood-and-behavior-101/psychosis
• Fordham S. RCEM Learning. Delirium in the Elderly. Online [cited 28 January 2022]. Available from: https://www.rcemlearning.co.uk/reference/delirium-in-the-elderly
• Liaison Psychiatry. In: Oxford Handbook of Psychiatry. 4th ed. Ed. Semple D and Smyth R. Oxford: Oxford University Press; 2019. Pp. 839-880.
• Marder S. Psychosis in adults: Epidemiology, clinical manifestations, and diagnostic evaluation [Internet]. Stein M, Friedman M, editors. UpToDate. 2021 [cited 18 January 2022]. Available from: https://www.uptodate.com/contents/psychosis-in-adults-epidemiology-clinical-manifestations-and-diagnostic-evaluation
• National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications [Internet]. NICE. 2017 [cited 16 January 2022]. Available from: https://www.nice.org.uk/guidance/cg100
• Orrin Devinsky. Postictal Psychosis: Common, Dangerous and Treatable.  Epilepsy Currents. March 2008. 8(2):31-34.
• Epilepsy Society. Seizure types. Online [cited 5 November 2022]. Available from: https://epilepsysociety.org.uk/about-epilepsy/epileptic-seizures/seizure-types