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A 40-year-old Man with Acute Psychosis
Sanjeev Kumar, MD; and Azziza Bankole, MD
T
he patient is a 40-year-old
white man who was admitted to our inpatient service
involuntarily on a court order for
acute psychosis. He had been expressing bizarre delusions about
“the devil” and winning the lottery.
He expressed paranoid delusions
about people being after him for his
money. He also experienced auditory and visual hallucinations. He did
not have any disorganized thoughts
or behavior outside of this delusional system and did not show any
negative symptoms of psychosis.
He did not have any suicidal or
homicidal thoughts and was involuntarily committed to treatment based
on his inability to take care of himself. He did not have manic or depres-
Azziza Bankole, MD, is Assistant Professor, Virginia Tech Carilion School of Medicine, and Geriatric Psychiatrist, Carilion
Clinic Centre for Healthy Aging, Roanoke,
VA. Sanjeev Kumar, MD, is Psychiatry Resident, Department of Psychiatry, Virginia
Tech Carilion School of Medicine.
Address correspondence to: Azziza
Bankole, MD, 2001 Crystal Spring Ave.,
Suite 302, Roanoke, VA 24014; or e-mail
[email protected].
Dr.Bankole and Dr.Kumar have disclosed
no relevant financial relationships.
doi: 10.3928/00485713-20101123-02
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sive symptoms. He reported that he
had stopped drinking alcohol about a
week before the index admission. He
denied experiencing any withdrawal
symptoms, such as tremors, diapho-
He had ... bizarre delusions
about ‘the devil’ and winning
the lottery ... paranoid
delusions about people being
after him for his money.
resis, or seizures, and there was no
report of altered sensorium since he
had his last drink.
The patient had a history of generalized anxiety disorder and had been
prescribed citalopram, sertraline, and
quetiapine. He was not taking any of
these medications at the time of his
hospitalization. He did not have any
history of psychotic episodes or suicidal behavior. He had been admitted
once previously for depression and
anxiety symptoms.
He gave a history of chronic alcohol use with recurrent remissions
and relapses. He reported consuming one 6- to 12-pack of 12-oz beers
every day since his teenage years.
He had no history of delirium tre-
mens in the past. He gave a remote
history of marijuana use.
The patient is a high school
graduate. He was unemployed and
was on disability at the time of this
admission. He was separated from
his wife and had no children.
He had a history of generalized seizure disorder after a head
injury 17 years before the index
admission. He was noncompliant
with phenytoin but did not report
any seizures in the recent past. He
had no family history of psychotic
illnesses or other diagnosed anxiety/affective illnesses. There was
a positive family history of alcohol dependence in several first-degree relatives.
Physical exam did not reveal any
relevant focal abnormalities, and
vitals were unremarkable. Urine
screens were negative for cannabinoids, opioids, benzodiazepines,
and amphetamines. His blood alcohol level was less than 0.01 mg/dL.
Renal function tests and liver function tests were normal. CT scan of
the head revealed no acute findings.
TSH, vitamin B12, and folate levels were normal.
Mental status examinations
were significant for the presence
of paranoid delusions and a complete lack of insight. He expressed
PSYCHIATRIC ANNALS 40:12 | DECEMBER 2010
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case challenges
delusional ideations. Auditory
and visual hallucinations were
not present at the time of exam.
His thought process was not disorganized outside his delusional
system. There was no euphoria
or pressured speech, and the patient was fully alert and oriented
to time, place, and person. He had
a mini-mental status examination
(MMSE) of 28/30.
When he was initially admitted
to our acute inpatient psychiatric
facility, his delusions persisted. He
reported one episode of hallucinations in which he reported “seeing
cats” in his room. He did not develop any physical symptoms characteristic of alcohol withdrawal
and was completely alert and ori-
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ented throughout his hospital stay.
He was given vitamins, including
thiamine and mineral supplements.
There was no euphoria or
pressured speech, and the
patient was fully alert and
oriented to time, place,
and person.
Psychosis was managed with olanzapine titrated up to 20 mg.
He responded well to the medication, and the intensity of his delusions decreased. He was also
started on citalopram for anxiety. He
gradually recovered and was able to
develop improved insight into his
symptoms. He was discharged with
outpatient case management services
on 20 mg of olanzapine and 40 mg of
citalopram once daily after 10 days
of hospital stay. His delusions and
hallucinations had ceased.
He remained symptom free for
several months after this hospital
stay. He stopped taking his medications shortly after his discharge. He
was hospitalized a year later with
suicidal ideation and auditory hallucinations after relapsing on alcohol. He again responded well to an
antipsychotic (risperidone) and was
discharged in stable condition after
10 days of hospital stay.
(See page 602 for diagnosis.)
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case challenges
D I A G N O S I S
Alcohol-induced
Psychotic Disorder
DISCUSSION
Alcohol-induced psychotic disorder has been known to the scientific community for centuries and
was first described as a separate entity by Marcel in 1847.1 It is a syndrome characterized by “hallucinatory or delusional states with clear
or relatively clear consciousness.”2
Since then, it has been known by
various names, including “drunken
madness” to “hallucinatory insanity of drunkards” to alcoholic mania, and has existed as psychoses
associated with organic brain syndromes and alcoholic hallucinosis
in the Diagnostic and Statistical
Manual of Mental Disorders, 2nd
edition (DSM-II) and DSM-III,
respectively.1,3-5 It was named “alcohol-induced psychotic disorder”
(AIPD) in DSM-IV6 and is classified along with other substance-induced psychotic disorders.
Despite profound implications
upon treatment and prognosis,
there is a relative paucity of literature and a lack of clear guidelines
about diagnosis and treatment of
this disorder.7-10
Review of the past 25 years of
literature suggests that there are
only a few studies looking into this
important entity. The estimates of
actual prevalence of the disorder vary. Different studies report
prevalence rates of 0.4% to 7.4%
among patients in alcohol treatment programs.8,11 Most authors
agree that it is a distinct diagnostic
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entity with a different epidemiology and distinct pathophysiological correlates from schizophrenia
or any other primary psychotic
disorder.1,3,7,12-15
There has been some evidence
pointing toward thalamic hypoperfusion as the underlying mechanism.16 However, it is not clear
whether it is related to alcohol use
itself or if it is independently related to this kind of psychosis.17
... it has been known by
various names, ranging
from ‘drunken madness’
to ‘hallucinatory
insanity of drunkards’
to ‘alcoholic mania’ ...
Also, a recent prospective study
by Jordaan et al. has failed to duplicate this observation.12
The current set of DSM-IV criteria have been questioned because
they seem to poorly correlate with
the etiopathogenesis and natural
history of the illness.18 Symptoms
have been described as sudden onset of hallucinations (most commonly auditory) and/or paranoid
delusions in a patient with clear
sensorium. There must be a temporal association with chronic alcohol
abuse/dependence and an absence
of a primary psychotic disorder.
The characteristic features of
AIPD, which differentiate it from
primary psychotic disorders, have
been identified as late age of onset (late 40s), absence of formal
thought disorder, negative family history of schizophrenia, and
positive family history of alcohol
dependence.3,7,15,19,20 There is also
evidence for positive association
with the diagnosis of alcohol dependence, shorter duration of illness in most cases, and less functional impairment but an elevated
risk of suicide consequent to persecutory delusions.1,3,7,13
Visual hallucinations of “delirious type” were seen in up to 75%
of alcohol withdrawal delirium but
not at all in “alcohol hallucinosis”21 and may be used to distinguish it from alcohol withdrawal
delirium. Visual hallucinations in
clear sensorium may be seen in
15% to 43% of patients.1,7,14 This
was also the case with our patient.
The long-term prognosis of the
AIPD is better than schizophrenia,
with only a small percentage progressing to a chronic psychotic illness. The incidence of relapse has
been found to be directly related to
relapse of drinking rather than discontinuation of antipsychotic medications.1,3,14,15,22 Regarding management, there is an emphasis on
the need for admission because the
risk for suicide might be high.21
There are no clear guidelines
about the selection of the drug,
dosage, or the length of treatment
required. One study has advocated
the use of risperidone,9 and another one by the same author has
reported similar efficacy of typical
and atypical antipsychotic agents.
There has been one, double-blind,
controlled study advocating the
use of valproate,23 however; it has
been criticized for methodological
flaws.24 As such, the use of medi-
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cations other than antipsychotics
in the treatment of AIPD also warrants further attention.
CONCLUSION
Based on literature review and
clinical experience, AIPD is a distinct diagnostic entity with a distinct
pathogenesis and long-term outcome.
The prevalence of AIPD seems to be
grossly underestimated in view of
the widespread presence of alcohol
abuse/dependence. This may be due
to lack of awareness about the diagnosis. It also might be overshadowed
by co-occurrence with other substance-induced psychotic disorders
and primary psychotic disorders,
which are often difficult to separate.
Patients who are misdiagnosed
with schizophrenia are likely to get
prolonged antipsychotic treatment,
which might not be warranted in
all the cases. Also, failure to distinguish AIPD from withdrawal states
may result in the withholding of
treatment, resulting in prolonged
morbidity. The need for increased
awareness among clinicians and
further large-scale prospective studies cannot be overemphasized.
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