Drug-induced psychosis refers to a syndrome of psychotic symptoms that results from exposure to a substance and persists beyond bodily elimination of the substance. In some cases, psychosis can result from withdrawal, as well. While symptoms may be similar to other disorders with psychotic features, they will vary depending on the substance, dosage, frequency of use, and comorbidities.
What Is Psychosis?
Psychosis is a syndrome characterized by a disconnect from reality, whereby the cause can be a preexisting medical or psychiatric condition, as well as external substances and trauma. Symptoms can be observed in several personality, mood, or psychotic disorders (e.g., schizophrenia, bipolar disorder, schizotypal personality disorder, etc.). In other cases, psychosis may occur due to a neurological condition, such as Huntinigton’s or a brain tumor. Exhibition of symptoms will vary depending on the cause of the psychosis, but episodes will typically include similar symptoms.
The key characteristics of psychosis are:
- Delusions: Distorted beliefs that, despite possibly having a kernel of truth, are not supported by the overwhelming evidence accessible to most other objective, non-psychotic observers.
- Hallucinations: Sensory experiences, in any sensory modality, that can take the form of seeing, hearing, or tasting things that aren’t really there.
- Disorganized speech: Speech that does not make logical sense or is incoherent; or, the repetition of the same word or phrase over and over.
- Disorganized behavior: Behavior that does not fit a given situation.
- Negative symptoms: Absence of typical, common, or normal features that most individuals regularly exhibit, such as blunted affect.
What Is Drug-Induced Psychosis?
Many substances can induce a psychomimetic (i.e., “mimicking psychosis”) response, producing psychotic symptoms similar to those seen in formal psychotic disorders. These symptoms may occur during a period of intoxication and then fade as the substance is eliminated from the body with time. During the period of intoxication and detoxification, individuals are usually aware that their psychotic symptoms are caused by the ingested substance. However, when psychomimetic symptoms persist beyond detoxification, a diagnosis of substance-induced psychotic disorder (a.k.a., “drug-induced psychosis”) may be appropriate. It is estimated that 7-25% of individuals presenting with acute psychotic symptoms for the first time are experiencing this.1
Substance-induced psychotic disorder is classified in the DSM-5 under Schizophrenia Spectrum Disorders and it can be challenging, even for clinicians, to differentiate them from primary psychotic disorders.
Below are key distinguishing factors of drug-induced psychosis:
- Age: While age of onset for certain primary psychotic disorders, like schizophrenia, is typically from the late teens to early 30s, many cases of substance-induced psychosis occur outside that age range.
- Family history: There is a stronger genetic/heritability link with primary psychotic disorders than with substance-induced psychosis.
- Symptoms: Substance-induced psychosis is associated with fewer positive and negative symptoms than primary psychotic disorders, but more affective and anxiety-related symptoms.
- Duration: Substance-induced psychoses are relatively brief by nature, lasting from days to weeks. Primary psychoses are often a lifelong disease with acute episodes alternating with periods of remission.2
- Good premorbid functioning: Before the onset of psychosis, individuals with substance-induced psychosis generally don’t exhibit thought disorder or behavioral disturbances, as is sometimes seen before acute episodes of schizophrenia.
How Does Drug Use Cause Psychosis?
Most of the drugs that elicit psychotic symptoms work by altering neurotransmitters in the brain. Neurotransmitters work together–not in isolation–and changes to one will usually affect others. Depending on the drug, mechanisms of action may vary. However, most psychomimetic effects are caused by dopamine and glutamate changes in the prefrontal cortex and midbrain. One exception is that psychedelics (e.g., LSD, psilocybin, MDMA/”ecstasy”) typically modulate serotonin (5-HT) in these regions to produce mind altering effects.
Different clusters of psychotic symptoms are caused by different neurotransmitter mechanisms. For example, stimulants and THC tend to evoke paranoia; LSD elicits visual hallucinations; and amphetamines and cocaine yield persecutory delusions and hallucinations of bugs crawling on oneself. Furthermore, some drugs, like methamphetamines and cocaine, engage the brain’s reward circuit more than others, and are thus more addictive–leading to heavier use and prolonged psychotic symptoms.
How Long Does Drug-Induced Psychosis Last?
Drug-induced psychotic symptoms may start during intoxication and last beyond elimination of the substance from the body. Diagnostically, psychotic symptoms that present during drug use are classified as “intoxication,” while the term “drug-induced psychosis” is reserved for symptoms persisting for days or weeks after detoxification.1 Sometimes, drug-induced psychosis converts to a chronic, lifelong primary psychotic disorder, like schizophrenia.
The duration of intoxication and subsequent drug-induced psychosis depends on the substance type, dose, individual tolerance, comorbidity, and other factors. Some drugs may cause long-term changes to brain pathways, in which psychotic symptoms may persist for longer.
Symptoms of Drug-Induced Psychosis
Drug-induced psychotic symptoms will vary depending on the drug and its associated neurotransmitters. While the DSM-5 requires the presence of delusions and/or hallucinations for a diagnosis of substance-induced psychosis, other positive, negative, and cognitive symptoms common to primary psychotic disorders may also appear.1
Common symptoms of drug-induced psychosis include:
- Hallucinations: Hallucinations are perceptions of things that aren’t really there, and shouldn’t be confused with perceptual distortions/illusions. Many hallucinogenic drugs may cause perceptual distortions, but not necessarily true hallucinations. Hallucinations may be visual, tactile (e.g., such as the sensation of bugs crawling on one’s skin), or auditory, depending on the drug and individual.
- Delusions: Delusions are beliefs that have little or no basis in reality. Persecutory delusions–that one is being followed or targeted–are the most common type found with drug-induced psychosis, especially for amphetamines, cocaine and cannabis.
- Paranoia: Related to delusions, feelings of suspiciousness are fairly common in a drug-induced psychotic episode for cannabinoids and stimulants.
- Panic attacks: Extreme anxiety may lead to feelings of panic, especially when hallucinations or delusions are unpleasant. The mood and content of hallucinations and delusions induced by various psychotropic drugs are often not predictable.
- Agitation: A state of irritability and restlessness is a common symptom of drug withdrawal, but can also be present beyond acute withdrawal as part of a drug-induced psychotic state.
- Disorganized thinking: Cognitive impairments, such as illogical thinking, may accompany hallucinations and delusions.
- Disorganized behavior: Inappropriate behavior may occur in response to hallucinations, delusions, or cognitive impairment.
- Lack of insight: This is a key characteristic distinguishing drug intoxication from drug-induced psychosis. During intoxication, the person is usually aware that hallucinations, delusions or perceptual distortions are due to the substance ingested. However, during a drug-induced psychotic episode (or primary psychotic episode), the individual is not aware of the connection between substance and symptom.
Drug-Induced Psychosis vs. Drug-Induced Schizophrenia
Certain drugs may cause symptoms that mimic schizophrenia or related psychotic disorders (i.e., they are psychomimetic). Due to this similarity, the terms drug-induced schizophrenia and drug-induced psychosis have been mistakenly used interchangeably. However, they refer to different conditions, with the former term being an outdated misnomer.
The link between schizophrenia and drug use is complex and only partially understood. It’s often challenging for clinicians to differentiate between psychosis caused by a substance, versus schizophrenia. Schizophrenia is a primary psychotic disorder, caused by factors other than consumption of a substance. However, schizophrenia’s onset can be triggered or exacerbated by certain substances, especially in the late teens to early 30s. Indeed, drug-induced psychoses can convert to a primary psychotic disorder, but that can only be determined after at least a month of abstinence from the substance. This conversion of drug-induced psychosis to a primary psychotic disorder or bipolar disorder occurs in 46% of cannabis-induced psychosis, 32.3% of amphetamine-induced psychosis, and 24% of hallucinogen-induced psychosis cases.3
On average, primary psychosis patients have an earlier age of onset than drug-induced psychosis patients, stronger family history of psychotic disorders, less insight into the cause of symptoms, more positive and negative symptoms, fewer depressive symptoms, and less anxiety.
What Substances Can Cause Psychosis?
The list of substances that can cause psychotic symptoms is continually increasing, as new synthetics enter the market. Drugs of misuse that can lead to psychotic symptoms include stimulants, cannabinoids, psychedelics, and cathinones. The amount of each substance that would induce psychotic symptoms may be affected by metabolic rate and amount ingested, other medications, and comorbidities.
Substances that may lead to psychosis include:
THC is the active ingredient in marijuana that can cause psychotic symptoms, such as delusions, hallucinations, and disorganized thinking or behavior. Though psychomimetic effects are temporary for most, psychotic symptoms occur in approximately 15%-50% of cannabinoid users.5,7,8
Cocaine can also induce psychotic symptoms in approximately 68% of dependent users, especially with repeated administrations (i.e., binging) and higher doses. Younger users are more likely to experience psychotic symptoms. Estimates of cocaine use leading to substance-induced psychotic disorder vary in the literature from 6%-40.5%.5,7
The most common psychotic symptoms reported with cocaine use are paranoid delusions (90% of users experiencing psychotic symptoms), and hallucinations (96% of users experiencing psychotic symptoms). Hallucinations are commonly auditory, but can also be visual, and paranoia manifests in the form of suspiciousness and irrational distrust of others.5,7
Methamphetamine (a.k.a., “Meth”) is a highly addictive stimulant that can lead to substance-induced psychosis in 17-43% of users.10
The most common symptoms reported include persecutory delusions (occurring in 84% of individuals with psychotic symptoms), auditory and visual hallucinations (69% and 65%, respectively), hostility (53%) and conceptual disorganization (36%).
Methamphetamine works by increasing dopamine and glutamate in the ‘reward’ (mesocorticolimbic) circuitry of the brain. In addition to transient neurotransmitter changes, these drugs can damage cortex and dysregulate glutamate pathways connecting the thalamus and cortex which is what might contribute to psychotic symptoms.
Hallucinogens (a.k.a., psychedelics) are categorized in two classes–classic and dissociative.6 Hallucinogens can be addictive, but most drugs in this class do not lead to drug-induced psychosis.6 Only 20.9% of LSD users and 18.8% of psilocybin users convert to experiencing true hallucinations or delusions.7
While intoxicated, users may experience perceptual distortions involving time, shape, color, movement, size, and even a blending of senses (i.e., synesthesia) like hearing color or seeing sounds. True hallucinations are not as common as perceptual distortions, when the user is often aware that the altered state of mind is due to the substance.
Ecstasy is a synthetic amphetamine that shares properties with both stimulants and hallucinogens, and works by increasing serotonin, dopamine, and norepinephrine. Primarily a mood enhancer, ecstasy can elicit feelings of energy, euphoria, and intense love for oneself or others. Though distorted perceptions may occur with acute use, few true psychotic symptoms are reported during intoxication (4.3%).7 However, when used chronically, this drug can cause long-term neurotoxicity (i.e., lasting changes to serotonin levels) and persistent psychotic symptoms may ensue, such as delusions of grandeur, paranoia, visual hallucinations, and conceptual or behavioral disorganization.11
PCP and Ketamine
Among a small percentage of users, PCP and ketamine can cause positive, negative, and cognitive symptoms typical to psychosis, even after the drug is eliminated from the body. Psychomimetic symptoms may depend on heaviness of use, but include hallucinations, delusions, disturbed emotion and affect, decreased motivation, among others. Persistent psychotic symptoms triggered by PCP can last for days or up to six weeks, while psychotic symptoms resulting from ketamine use are more mild and short-lived.12,13
It is estimated that ketamine induces psychomimetic symptoms in a relatively low percentage of users (3.9%). While estimates of psychosis are not available for PCP usage, it is more potent than ketamine in eliciting psychotic symptoms, and is thus no longer used in human medicine.7
Chronic use of gamma-hydroxybutyric-acid (GHB) can lead to negative symptoms like those seen in primary psychotic disorders, such as apathy, alogia, anhedonia, and asociality. However, positive psychomimetic symptoms may arise during withdrawal from GHB in a relatively low percentage of individuals (1.9-3.5%) and include hallucinations, delusions, disorganized speech and behavior and agitation.7,14 When these symptoms last beyond acute withdrawal, GHB-induced psychosis may be designated.
An estimated 0.4-7% of individuals with alcohol dependence will experience alcohol-induced psychotic disorder.15,16 Also referred to as alcohol hallucinosis, psychomimetic symptoms can include hallucinations and delusions.16 Although for many, symptoms may abate over time with abstinence, they can become chronic in 10-20% of people with alcohol-induced psychosis, lasting upwards of 6 months. Alcohol hallucinosis is a condition distinct from the acute ethanol withdrawal state, delirium tremens. The neurophysiology of alcohol hallucinosis is not fully understood, but is thought to be related to glutamate-mediated NMDA receptors, dopamine and GABA.
Certain elements in one’s environment–such as lead, gasoline, glues, paint thinners, organophosphate insecticides, nerve gas, and anticholinesterase–have been shown to cause psychotic symptoms, although the prevalence of toxin-induced psychosis is not clear.1,17,18,19
How Is Drug-Induced Psychosis Treated?
The first step in treating substance-induced psychotic symptoms is to remove the offending substance from one’s system. This is usually best accomplished in a medical setting with support staff to help avoid harm to the individual or surroundings. In many cases, treatment may involve abstinence. In other cases, medications might be administered to help the elimination process or to counteract the effects of the offending agent.18 When removal of the offending substance leads to withdrawal symptoms, stabilization drugs may be given and gradually reduced to ease the individual through withdrawal.
Although withdrawal from certain addictive drugs (e.g., alcohol, heroin) can give rise to psychotic symptoms, drug-induced psychosis refers to the symptoms persisting after acute withdrawal. For psychotic symptoms extending beyond a month, a clinician will have to distinguish whether the condition has converted to a primary psychotic disorder (for which a long-term treatment plan would have to be established) or just needs longer to resolve.
Treatment of Underlying Associated Conditions
Drug-induced psychosis presents two distinct, but related, issues that may require treatment–substance use and psychosis. Treatments for a substance use disorder and a psychotic disorder may occur in parallel or sequentially. Being that unaddressed symptoms of depression and anxiety may contribute to drug misuse and pursuant drug-induced psychosis, an integrated approach is most effective.
Treatment for drug-induced psychosis comorbid conditions may include:
- Abstinence: Abstaining from further substance use is important for optimal intervention.
- Medication management: After an individual is stabilized, they should be evaluated for any medications that might be helpful in treating underlying conditions that led to drug use.
- 12-step programs: Programs like Alcoholics Anonymous (AA) and Narcotics Anonymous (AA) involve flexible, but regular, attendance to group meetings, adherence to the twelve steps, and usually working with a sponsor or elder in the program.
- Psychosocial training: Social Skills Training (SST) can be particularly useful–especially in the context of psychotherapy–to help individuals develop skills that are often deficient in those with psychosis and drug dependence. They may involve individual and group work.20
- Psychotherapy: Individual therapy may focus on concrete goals–like reality testing of hallucinations and delusions, verbal skills enhancement, maintenance of ADLs, and medication compliance. Insight-oriented therapy may foster a more abstract understanding of the factors contributing to the substance use that trigger one’s psychotic symptoms.
- Family engagement: Family therapy often focuses on the ways an individual’s family system can better prevent the afflicted individual from undue anxiety, frustration, or confusion. Additionally, having family members join for doctor and therapy appointments can make a big difference in the treatment.21
- Contingency management: Involves reinforcing positive behaviors like abstinence, treatment attendance, and medication adherence with “agreed on, immediate, tangible rewards.”22 It is particularly effective for individuals with a dual diagnosis of a primary psychotic disorder and substance misuse.
Recovery from Drug-Induced Psychosis
Recovery from drug-induced psychosis often entails a detailed treatment plan and effective coping skills.
Below are some tips for recovering from drug-induced psychosis:
- Plan ahead: When you are experiencing drug-induced psychosis, the altered state of mind may preclude you from figuring out how to get help. Consider establishing a relapse prevention plan, including identifying someone you can contact if you’re experiencing disturbing symptoms.
- Stress management: Misuse of drugs is commonly a coping mechanism for dealing with stress. Avoiding stressful situations is not always possible, and learning techniques to manage stress is important.
- Avoid drugs and alcohol: Some individuals are more vulnerable to psychotic symptoms than others due to genetics, comorbidities, or environmental factors. Avoiding the offending substance is ideal. If using the drug is not just recreational, but a form of self-medication, consider substituting with well-researched psychiatric medications that are tested to ensure purity and potency.
How to Help Someone Experiencing Drug-Induced Psychosis
It can be unsettling to witness someone experiencing drug-induced psychosis. It is generally recommended to stay calm and try not to agitate the individual. If the person has not already received medical attention, encourage the person to get professional help or call 911 if you are not sure if the individual is at risk for harm to oneself or others. As drug-induced psychosis can last for weeks, it is important to be patient and supportive to the person as they recover.
You can support a loved one experiencing or recovering from drug-induced psychosis by:
- Seeking medical assistance: Often drug-induced psychosis comes with symptoms that might be difficult to handle at home, putting both the individual and others at risk for harm. Don’t be afraid to call 911 sooner rather than later. There may also be treatments available in a clinical setting to help the individual deal with the psychotic symptoms.
- Encouraging treatment: While substance-induced psychosis may result from prescribed medicines or toxins, it is more common that this condition results from drug misuse. The person experiencing psychosis may require drug rehabilitation to avoid a recurrence of psychosis or other debilitating consequences of drug misuse.
- Checking-in: If the person lives alone, try to check in on the person frequently or arrange for nursing assistance until the individual is completely recovered. Without being too overbearing, ask the person how they are feeling and try to do more listening than speaking. Try to be a calm, nonjudgmental presence for the person.
- Being patient: It can take weeks for symptoms to resolve. During recovery, individuals may not be able to engage in normal household duties and work activities. Patience and support from family members is important in giving the individual the time and space to recover.
- Join a support group: A support group can provide a safe, validating environment for family members, and also a forum to learn tips and strategies. When family members take the time to educate themselves about psychosis, drugs, and how to best help their loved one, the individual tends to be more successful in overcoming symptoms and having a successful recovery.21,23
- Self-care: Supporting your family member through persisting psychotic symptoms can be challenging, frustrating, and emotionally exhausting. It is imperative that you take care of yourself as well to recharge, refresh, and de-stress. Take time to engage in self-care to keep yourself strong for others.
Drug-induced psychosis can manifest in a variety of ways depending on the offending substance. Symptoms that persist beyond intoxication or acute withdrawal can be frightening for the individual and others. While the condition is relatively brief, it can convert to a primary psychosis or reveal a vulnerability to psychosis. Professional help can often be helpful in treating not just the drug-induced psychosis, but also underlying causes that may have led to drug use in the first place.