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case challenges • case challenges • case challenges 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: 10.3928/00485713-20101123-02 600 | PsychiatricAnnalsOnline.com 4012CaseChallenges.indd 600 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 12/6/2010 3:37:53 PM 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- PSYCHIATRIC ANNALS 40:12 | DECEMBER 2010 4012CaseChallenges.indd 601 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.) PsychiatricAnnalsOnline.com | 601 12/6/2010 3:37:53 PM 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 602 | PsychiatricAnnalsOnline.com 4012CaseChallenges.indd 602 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- PSYCHIATRIC ANNALS 40:12 | DECEMBER 2010 12/6/2010 3:37:53 PM case challenges 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. REFERENCES 1. Glass IB. Alcoholic hallucinosis: a psychiatric enigma — 1. The development of an idea. Br J Addict. 1989;84(1):29-41. PSYCHIATRIC ANNALS 40:12 | DECEMBER 2010 4012CaseChallenges.indd 603 2. Cutting J. A reappraisal of alcoholic psychoses. Psychol Med. 1978;8(2):285-295. 3. Surawicz FG. Alcoholic hallucinosis: a missed diagnosis. Differential diagnosis and management. Can J Psychiatry. 1980;25(1):57-63. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 2nd ed. Washington, DC: American Psychiatric Publishing; 1968. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: American Psychiatric Publishing; 1980. 6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Publishing; 1994. 7. Jordaan GP, Nel DG, Hewlett RH, Emsley R. Alcohol-induced psychotic disorder: a comparative study on the clinical characteristics of patients with alcohol dependence and schizophrenia. J Stud Alcohol Drugs. 2009;70(6):870-876. 8. Soyka M, Täschner B, Clausius N. Neuroleptic treatment of alcohol hallucinosis: case series. Pharmacopsychiatry. 2007;40(6):291-292. 9. Soyka M, Wegner U, Moeller HJ. Risperidone in treatment-refractory chronic alcohol hallucinosis. Pharmacopsychiatry. 1997;30(4):135-136. 10. Soyka M, Botschev C, Völcker A. Neuroleptic treatment in alcohol hallucinosis -- no evidence for increased seizure risk. J Clin Psychopharmacol. 1992;12(1):66-67. 11. Tsuang JW, Irwin MR, Smith TL, Schuckit MA. Characteristics of men with alcoholic hallucinosis. Addiction. 1994;89(1):73-78. 12. Jordaan GP, Warwick JM, Hewlett R, Emsley R. Resting brain perfusion in alcoholinduced psychotic disorder: a comparison in patients with alcohol dependence, schizophrenia and healthy controls. Prog Neuropsychopharmacol Biol Psychiatry. 2010;16;34(3):479-485. 13. Caton CL, Drake RE, Hasin DS, et al. Differences between early-phase primary psychotic disorders with concurrent substance use and substance-induced psychoses. Arch Gen Psychiatry. 2005;62(2):137-145. 14. Soyka M. Psychopathological characteristics in alcohol hallucinosis and paranoid schizophrenia. Acta Psychiatr Scand. 1990;81(3):255-259. 15. Glass IB. Alcoholic hallucinosis: a psychiatric enigma — 2. Follow-up studies. Br J Addict. 1989;84(2):151-164. 16. Soyka M, Koch W, Tatsch K. Thalamic hypofunction in alcohol hallucinosis: FDG PET findings. Psychiatry Res. 2005;139(3):259-262. 17. Soyka M, Dresel S, Horak M, Rüther T, Tatsch K. 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Pharmacological treatment of alcohol hallucinosis. Alcohol Alcohol. 2008;43(6):719-720. PsychiatricAnnalsOnline.com | 603 12/6/2010 3:37:54 PM