Primary or Substance-Induced Psychosis? How to Tell and Treat

This transcript has been edited for clarity. Hello, my name is Dr Adjoa Smalls-Mantey, and today I wanted to speak with you about primary vs substance-induced psychosis.First of all, what is psychosis? Psychosis is a state where you are not in touch with reality. Many hallmarks of psychosis include hallucinations — auditory, visual, or tactile. People may also experience delusions of grandeur, believe that unrelated events are referring to them, develop paranoid delusions, or have disorganized thought. When you have substance-induced psychosis or primary psychosis, those are all features that you see.Let’s review the different types of primary psychoses. Those can include:Schizophrenia spectrum disorders, including brief psychotic disorder, schizophreniform disorder, schizophrenia, and schizoaffective disorderMood disorders with psychotic features, such as bipolar disorder with psychotic features, or major depressive disorder with psychotic featuresDelusional disorderCommon Causes of Substance-Induced and Secondary PsychosisWhen you’re thinking of substance-induced disorders, there are an array of substances that can cause these. However, we’re usually talking about illicit or recreational substances:Cannabis (marijuana) CocaineMethamphetamineHallucinogens (LSD, psilocybin, PCP)History Is Your Most Powerful Diagnostic ToolBut today what we’re talking about is substance-induced vs primary psychotic disorders.How do you tell? The first thing is the history. That is key. You also want to get a timeline from that history. When you’re trying to determine whether psychosis is substance-induced, the first question is whether the patient took a substance capable of causing hallucinations or psychosis during intoxication or withdrawal.Someone with substance-induced psychosis can usually identify a specific point when symptoms began: “I was completely normal and then all of a sudden I started acting weird.” Although patients themselves may lack insight, family members or friends often recognize an abrupt behavioral change. It’s very clear-cut.That psychosis, whether it is hallucinations or delusions, can last for about a couple of days to a month, especially in cases of cannabis or methamphetamine. Beyond a month, we start to think about another primary psychotic disorder.By contrast, primary psychotic disorders often develop gradually over weeks to months. Family members or friends may notice that someone is talking to themselves, responding to things that aren’t there, or behaving differently, but there usually isn’t a single, clearly identifiable moment when symptoms began.Like I talked about with the substance-induced psychotic disorder, if those symptoms persist a lot longer than a month or so in the absence of using any other substances, then it is more likely a primary psychotic disorder.Onset of SymptomsNext, consider the patient’s age at symptom onset. If somebody has had symptoms lasting for a couple of weeks or months, and they are in that range of their late teens to late twenties, we might think, “Okay, this is a primary psychotic disorder like schizophrenia.”However, if they had an abrupt onset of symptoms at any age — from adolescence through older adulthood — then it’s more likely due to a substance, whether that substance is a recreational drug or a medication. The time it takes for symptoms to resolve is often an indicator of whether this is substance-induced vs a primary psychotic disorder. If you remove what you think the offending substance is for a few days and the person gets better, more likely that it is a substance-induced psychotic disorder.Symptom Patterns Can Provide Important Clues We want to think about the type of symptoms somebody might be having. Primary psychotic disorders most often present with:Auditory hallucinationsDelusionsHowever, it is a bit rarer that somebody has visual and tactile hallucinations. Whenever somebody is mentioning those as symptoms, my first thought is, “Is this a substance?” Some substances like cocaine are known to cause more tactile hallucinations — or with alcohol or benzo withdrawal, people might have visual hallucinations.Visual hallucinations are also common in:Lewy body diseaseParkinson’s disease treated with levodopaFinally, you want to think about family history. If somebody has a history of people in their family having any spectrum of mental illness, but usually a psychotic disorder or bipolar disorder, it is very possible that they could have a primary psychotic disorder. If there’s no history whatsoever, then we’re thinking, “Okay, maybe this is just substances.”Cannabis and the Growing Diagnostic ChallengeSadly, nowadays I’m seeing more primary psychotic disorders that are being brought on by cannabis. So, standing on my little soapbox for a little bit, there is such a vast underestimation of the potency of today’s cannabis products, which contain higher concentrations of THC, the psychoactive component that can cause people to have more strong hallucinations and delusions. For some people that may have never developed schizophrenia, if they’re continually using cannabis, they may be tipped over into developing a permanent primary psychotic disorder. I often tell people it’s like a sleeping gene. The lights are off until heavy cannabis use turns the light on. You might have never developed schizophrenia, but then using so much cannabis can lead to that.I’ll get off my soapbox right now, but it’s definitely something to think about, and it’s so much harder for us to tease apart whether initially somebody is presenting with just a substance-induced psychosis from cannabis or whether this is a primary psychotic disorder with the very first presentation.Key Questions to Ask Before the Workup When evaluating whether somebody has a substance-induced vs a primary psychotic disorder, the first thing that you want to make sure is that you get a good history. Key history questions include:When did symptoms begin and how long have they been around?Was the onset abrupt or gradual?Has the patient used recreational drugs?Are they taking medications that can cause psychosis?Is there a prior psychiatric history?Can family or friends provide collateral information?Initial Evaluation and TestingStart by checking vitals. Make sure that somebody is stable because abnormal vitals can point to an ingested substance, a certain withdrawal — like in the case of alcohol or benzo withdrawal — and you want to make sure that you are treating that well.Then you want to test for substances, that can be a breathalyzer, a blood alcohol level, also urine toxicology screens. It is important to know that many drugs are not picked up on a routine urine toxicology, so some of the synthetic cannabinoids such as K2 or Spice or other things like LSD may not be on your routine drug screen. Whenever possible, ask patients directly what they have taken, because a negative drug screen does not exclude substance-induced psychosis.We’re also getting our routine labs because that can rule out other medical causes of psychosis:CMPCBCB12 and folate: Deficiencies can lead to psychosis, especially in older individuals that might have a greater propensity to those deficienciesSyphilis testing: Neurosyphilis can have psychotic features, and syphilis has been on the rise in certain regionsAlso, other neurological symptoms might indicate another physical condition. Additional testing may include:CT scan to rule out a tumorEEG if you think that there are seizuresAutoimmune encephalitis evaluationParaneoplastic testingThe list is vast, but the patient’s clinical picture will dictate the things that you should check for.Treating Substance-Induced vs Primary PsychosisFinally, what is the treatment? For someone that has a substance-induced psychosis, they’ve lost touch with reality but they still retain some insight and they’re fine, they’re able to keep it together, and it looks like they’re even starting to clear up by the time you’re talking to them or assessing them, you might just let them be. See if they metabolize. Sometimes within 24 hours, somebody can be perfectly fine.One time, a patient was telling me, “I am having a baby. Do not touch my belly,” and was adamant about that. We did our tests, and this was not accurate. We did an ultrasound. There was no baby. A day later, they were completely fine, and they knew that something was a little bit off. They were able to tell us what they had used.It can really be that abrupt. Just the next day they’re completely fine because the drug has metabolized. That person may not have needed any medications, as was the case with this individual.But, sometimes a person might be in such distress, or you think their psychosis is due to withdrawal from maybe alcohol or a benzodiazepine, so they will need a taper of benzodiazepines to make sure that they have a safe withdrawal, not to make it any worse.For some people that are really disturbed, the hallucinations are really bothering them, you can give them an antipsychotic. Typically, I prefer to use a first-generation antipsychotic.For people that have a primary psychotic disorder, it is indicated that you treat them with an antipsychotic, and the antipsychotics work very well for treating hallucinations, not as well for delusions, especially if someone has had it for a very long time.In delusional disorders, we sometimes see that people’s delusions may never completely go away, but they’ll have a little less anxiety around their delusions.With someone that has a primary psychotic disorder, it’s more likely that you’re going to be treating them for years or indefinitely on the antipsychotic. Whereas somebody that has a substance-induced psychotic disorder — if you’re starting a medication for them, maybe after a month where you think the drug has metabolized, they’re fine — you can wean them off and see how they do. If they’re completely fine and stable, leave them off.Key TakeawaysTo sum it all up, when you are trying to determine between a primary psychotic disorder vs a substance-induced psychotic disorder, the key thing is the history, knowing whether there has been ingestion of a substance or any other medication that could be causing somebody’s symptoms, and then the timeframe of their symptoms.Was it an immediate onset, and do their symptoms resolve pretty quickly with no residual effects? If that happens, it’s more likely to be a substance-induced psychotic disorder. However, if somebody’s symptoms had an insidious onset for weeks to months, they’re thinking or behaving oddly, that might point more to a primary psychotic disorder.With that, I hope that you have a little bit of a better understanding of how to tell the difference between these two. Thank you.Adjoa Smalls-Mantey, MD, DPhil, is an assistant clinical professor of psychiatry at Columbia University and an adjunct assistant professor of psychiatry at NYU Grossman School of Medicine in New York. She serves as president of the New York County Psychiatric Society and has held multiple leadership roles within the New York City district branch. Dr Smalls-Mantey has authored numerous scientific publications and contributes to ABC News as part of its medical unit. She is also an active speaker in community and media forums on mental illness, wellness, and public health.