Acute psychosis is still largely misunderstood and can be scary for those who encounter it. This page will provide a thorough overview of the condition and its causes, with a view to demystifying it a bit.
What is Acute Psychosis?
There are two types of acute psychosis: primary and secondary. Primary acute psychosis is a psychiatric condition involving visual and/or auditory hallucinations, delusions, nonsensical speech, and cognitive disturbances. Secondary acute psychosis is caused by a medical condition, especially a drug or alcohol addiction, and is often referred to as an acute psychotic break.
Psychiatric (primary) acute psychosis may be a symptom of:
- Bipolar disorder
- Drug addiction
- Prescription medication overdose
- Sleep deprivation
- Organic disorders (dementia, stroke, brain tumors)
Acute psychotic episodes affect about three percent of the U.S. population at least once in their lifetime. Every year nearly 100,000 teenagers and young adults in the U.S. have their first psychotic episode.
People often assume psychosis and schizophrenia are the same thing but they’re not. While acute psychosis is considered an immediate medical emergency, schizophrenia is not professionally diagnosed until the individual experiences six or more months of psychotic symptoms.
In addition, the biological cause of schizophrenia is thought to include genetic predisposition and an imbalance of brain neurotransmitters. Consequently, managing schizophrenia requires the long-term use of antipsychotic medications and intensive counseling. Although schizophrenia cannot be “cured,” persay, many who have the condition are able to live a good life when they take their medications as prescribed.
Acute Psychosis and Substance Addiction
Alcohol and Acute Secondary Psychosis
Chronic alcoholism, alcohol withdrawal syndrome, and alcohol poisoning are the most common reasons for acute secondary psychosis involving alcohol. When auditory hallucinations are predominantly seen in individuals experiencing alcoholic psychosis, doctors call this condition alcoholic hallucinosis. Positron emission tomography (PET) brain scans indicate severely reduced functioning of the thalamus and decreased blood flow within the frontal lobes in patients with alcoholic hallucinosis. In addition, dopamine and serotonin levels are extremely elevated in individuals suffering from acute alcohol psychosis.
General acute alcohol-induced psychosis may include auditory hallucinations as well as the following symptoms:
- Visual hallucinations
- Paranoid delusions
- Inability to speak coherently
- Total break with reality
Withdrawing from alcohol without the assistance of a medical detox team can raise one’s risks of alcohol withdrawal delirium (AWD). Signs of AWD resemble acute alcohol psychosis but may also include chest pain, muscle spasms, fever, and seizures. Symptoms often start within hours of a person’s last drink and rapidly intensify if drinking is not resumed. Those who’ve been heavy drinkers for a long time and who stop suddenly are at higher risk of AWD.
Drug Addiction and Acute Psychosis
Signs of drug-induced psychosis (DIP) are categorized as “positive,” “negative,” and “cognitive” symptoms, according to 2017 research in the journal Experimental Neurobiology. Since DIP presents symptoms nearly identical to schizophrenia, they are placed in the same categories as schizophrenia symptoms. The primary difference between schizophrenia and DIP is that schizophrenia is considered a heritable mental illness while DIP is an acquired and acute mental illness.
The most commonly seen DIP in emergency rooms is amphetamine-induced psychosis (AIP). Amphetamines associated with DIP are methamphetamine, cocaine/crack, and MDMA (Ecstasy).
Positive symptoms of DIP can include:
- Hallucinations (auditory, visual, olfactory, and tactile)
- Disordered/incoherent speech and thought
- Bizarre behaviors (standing for hours with arms raised above their heads, wearing layers of clothing in hot weather)
Negative symptoms of DIP can include:
- Inability to answer questions coherently: a simple “yes” or “no” question is answered with long, convoluted sentences
- Emotional flattening: no eye contact, frozen facial expression, lack of nonverbal body language
- Indifference to the environment/apathy/social withdrawal
- Anhedonia: inability to feel pleasure, satisfaction, or meaning
Cognitive symptoms of DIP can include:
- Deficits in focusing and concentration
- Memory loss
- Impaired judgment and reasoning
- Difficulty removing attention from one object (people with DIP may stare at a wall or painting for hours without being able to explain why they can’t change their focus)
The causes of DIP are similar to the causes of alcohol-induced secondary psychosis. Powerful stimulants like methamphetamine and cocaine significantly increase dopamine levels in the brain. A primary neurochemical instigator of addiction, dopamine motivates addicts to compulsively seek the pleasure provided to them by drugs. This flooding of the brain with excess dopamine can result in hallucinations, manic behavior, and acute psychotic episodes.
Diagnosing Alcohol or Drug-induced Acute Psychosis
The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) provides the following criteria for diagnosing this type of acute psychosis:
- Presence of “significant” delusions or hallucinations
- Evidence that the delusions or hallucinations can be medically attributed to substance addiction and/or withdrawal only
- Psychological examination of the individual reveals positive, negative, and cognitive signs of DIP
- Physical examination rules out head trauma, metabolic disorders, and other organic disorders that could be causing symptoms of DIP
Emergency room doctors will also order urine, blood, and glucose tests for acute psychosis patients who they think may have a drug or alcohol problem. Sometimes, after all, the issue may not be substance-related: Diabetics with low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia) may appear to be disoriented and delusional; a person experiencing a stroke could also seem confused and actively hallucinating.
After the patient is stabilized, benzodiazepines are often prescribed to reduce agitation and possible seizures associated with alcohol withdrawal. In some cases, atypical antipsychotics may be used to help sedate acutely psychotic individuals. Although antipsychotic medication usually takes several hours before alleviation of hallucinations is noticeable, they do offer a rapidly sedating effect.
Can Acute Psychosis be Successfully Treated?
The answer is “yes.” The nature of treatment can of course depend on whether the psychosis stems from a psychiatric diagnosis or substance abuse. For many years, patients with acute psychosis who ended up in the ER were often prescribed relaxants like benzodiazepines and conventional antipsychotic medications such as haloperidol. Today newer-class antipsychotic medications offer more options.
For those with acute psychosis from drug or alcohol abuse, the prognosis depends on whether they can abstain from addictive substances and if there is no severe brain damage. However, studies suggest that individuals with symptoms of psychosis due to substance abuse have a higher risk of developing primary schizophrenia or a schizo-affective disorder. In addition, there is a strong correlation between drug-induced psychosis and the age of the person. Younger drug users are more likely to eventually suffer from a primary psychotic disorder like bipolar disorder or schizophrenia
One study involving 55 cocaine users found that 90 percent of them had paranoid delusions, over half had psychotic symptoms, and nearly all subjects reported auditory and visual hallucinations. A meta-analysis of studies examining methamphetamine users indicated that the more frequently an addict used meth, the higher the risk of acute psychosis. In addition, the earlier onset of meth use coupled with long-term use further raised the chance that the addict would suffer acute psychotic episodes.
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