Continuing Education Activity

Psychosis associated with alcohol can occur with acute intoxication, alcohol withdrawal, and chronic alcoholism. Alcohol-related psychosis is also known as alcohol hallucinosis. Providers must be able to not only recognize and manage patients affected by this condition but must educate patients on ways to prevent alcohol-related psychosis. This activity reviews the evaluation and management of alcohol-related psychosis and highlights the role of the interprofessional team in the recognition and management of this condition.

Objectives:

• Identify the etiology of alcohol-related psychosis.
• Outline the typical presentation of a patient with alcohol-related psychosis.
• List the treatment options available for alcohol-related psychosis.
• Describe interprofessional team strategies for improving care coordination and communication to improve outcomes in patients with alcohol-related psychosis.

Introduction

Psychosis associated with alcohol can occur with acute intoxication, alcohol withdrawal, as well as in patients with chronic alcohol use disorder. The specific diagnosis of alcohol-related psychosis is also known as alcohol hallucinosis. It is a relatively rare consequence of alcohol use. However, it may be more prevalent than classically thought depending on the inclusion criteria used for diagnosis. In alcohol-related psychosis, symptoms of psychosis present during or shortly after heavy alcohol intake. Clinically, alcohol-related psychosis is similar to schizophrenia but has been found to be a unique and independent condition. It is characterized by hallucinations, paranoia, and fear.[1][2][3]

Etiology

There are a variety of hypotheses to describe the etiology of alcohol-related psychosis, but none of them can fully explain the development of acute or chronic hallucinations in certain patients with alcohol use disorder. Therefore, the exact etiology of alcohol-related psychosis is unknown. It is likely related to dopamine, serotonin, and other neurotransmitters.

Epidemiology

A 2015 Dutch literature review on alcohol-related psychotic disorder found that there is a 0.4% lifetime prevalence in the general population and a 4% prevalence in patients with alcohol dependence. The incidence is highest in working-age men. There is also a higher prevalence of alcohol-related psychosis in 1.) patients who became dependent on alcohol at a younger age, 2.) those with a low socioeconomic status, 3.) individuals who are unemployed or living on their pension, and 4.) those who live alone.  In patients with alcohol use disorder, paternal alcohol and mental health problems were found to be associated with a higher incidence of alcohol-related psychosis. Twin studies also suggest a genetic predisposition to the development of alcohol-related psychosis. Once diagnosed with alcohol-related psychosis, there is a 68% chance of re-admission and a 37% co-morbidity with other mental disorders. Patients with alcohol-related psychosis have a 5% to 30% risk of developing a chronic schizophrenia-like syndrome.[4]

Pathophysiology

The pathophysiology of alcohol-related psychosis is unclear. Several hypotheses exist. Some studies suggest that an increase in central dopaminergic activity and dopamine receptor alterations may be associated with hallucinations in patients with alcohol use disorder. However, serotonin may also be involved. Other studies imply that amino acid abnormalities may lead to decreased brain serotonin and increased dopamine activity leading to hallucinations. Elevated levels of beta-carbolines and an impaired auditory system have also been associated with alcohol-related psychosis. Neuro-imaging studies have suggested that perfusion abnormalities to various regions in the brain may be associated with the hallucinations in alcohol dependence.[4]

History and Physical

As with any form of psychosis, patients with alcohol-related psychosis may present with a wide range of symptoms. However, the presence of significant hallucinations or delusions must be evident. The psychosis is more extreme than what could potentially be attributed to alcohol intoxication or withdrawal. Special attention should be paid to mental status including flat affect or responding to internal stimuli. Additionally, a good physical exam needs to be done to look for possible trauma or infectious causes of altered mental status.

Evaluation

The majority of patients presenting with psychosis for the first time have some substance abuse. A detailed history is important in the evaluation of alcohol-related psychosis. Specifically, it is imperative to determine the patient's alcohol use history. It may be difficult to determine whether a patient’s psychotic symptoms are due to a primary psychotic disorder or due to substance use, including alcohol. This may be especially difficult in the emergency department where the history is frequently lacking. No family history of psychotic disorder in a patient who has a clear history of alcohol use supports the diagnosis of alcohol-related psychosis. Alcohol-related psychosis must be differentiated from other causes of psychosis and specifically from schizophrenia. When compared to schizophrenia, patients with alcohol-related psychosis tend to have significantly lower education levels, an onset of psychosis at an older age, more intense depressive and anxiety symptoms, and fewer negative and disorganized symptoms. Patients with alcohol-related psychosis also usually have better insight and judgment.[5][6]

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) states that the diagnosis of substance-induced psychotic disorder requires the presence of significant hallucinations or delusions. There must be evidence that the hallucinations or delusions started during or soon after substance intoxication or withdrawal or the substance used is known to cause the disturbance. The symptoms are not better explained by a psychotic disorder unrelated to substance use. The psychosis does not occur only with delirium. The symptoms cause clinically significant distress or difficulty with normal activity such as work or social interactions.

A detailed physical exam is also important. Stability of the patient, including airway, breathing, and vital signs must be assessed first. Special attention needs to be paid to general appearance including if the patient is unkempt, has a flat affect, smells of alcohol, or appears to be responding to internal stimuli. Additionally, the patient should be evaluated thoroughly for any sign of trauma, especially head trauma. Other causes of altered mental status must also be evaluated, including infection, trauma, metabolic causes such as liver disease, and electrolyte abnormalities. Therefore, CT imaging of the brain, urinalysis, urine drug screen, lab evaluation including electrolytes, liver function tests, ammonia, and toxicology screening may be indicated.

Treatment / Management

The priority is to stabilize the patient paying close attention to airway, breathing and vital signs. If the patient requires sedation due to alcohol-related psychosis, neuroleptics, such as haloperidol, have been considered the first-line medications for treatment. Benzodiazepines, such as lorazepam, are used if there is a concern for alcohol withdrawal and seizures. Certain atypical antipsychotics, such as ziprasidone and olanzpine, have also been used to help sedate patients with acute psychosis. Some patients may require the use of physical restraints to protect the patient as well as the staff. Patients with alcohol-related psychosis must also be evaluated for suicidality since it is associated with higher rates of suicidal behaviors. The prognosis for alcohol-related psychosis is less favorable than earlier studies had speculated. However, if the patient can abstain from alcohol, the prognosis is good. If patients are unable to abstain from alcohol, the risk of recurrence is high.[7][8][9]

Differential Diagnosis

• Bipolar disorder type 1

• Cannabis-related disorders

• Cocaine-related psychiatric disorders

• Delirium

• Delirium tremens (DTs)

• Hallucinogen use

• Major disruptive disorder, single or recurrent, with severe psychotic features

• Schizophrenia

• Stimulants

• Wernicke-Korsakoff syndrome

Complications

• Depression
• Suicide
• Major psychosocial impairment

Enhancing Healthcare Team Outcomes

In general, most cases of alcohol-related psychosis come to light when patients are admitted to the hospital and then develop withdrawal symptoms with or without delirium tremens. The presence of alcohol-related psychosis usually is an indicator of something very serious and if not treated promptly can lead to negative outcomes. Healthcare workers should be familiar with this disorder and make appropriate recommendations to specialists if they have such a patient. Besides psychosis, these patients have a much higher rate of anxiety, depression and suicide. In addition, the patients can be unpredictable and resort to violence. These patients need to be managed by an interprofessional team of allied healthcare workers to mitigate morbidity and mortality. The prognosis for most patients with alcohol-related psychosis is poor, and even with recovery, major neuropsychiatric deficits persist. [10][11](Level V)