Elsevier

Schizophrenia Research

Volume 197, July 2018, Pages 78-86
Schizophrenia Research

Clinical characteristics of primary psychotic disorders with concurrent substance abuse and substance-induced psychotic disorders: A systematic review

https://doi.org/10.1016/j.schres.2017.11.001Get rights and content

Abstract

Background

Distinguishing between a primary psychotic disorder with concurrent substance abuse (PPD + SA) and a substance-induced psychotic disorder (SIPD) can be diagnostically challenging. We aimed to determine if these two diagnoses are clinically distinct, particularly in relation to psychopathology. In addition, we aimed to examine the specific clinical features of cannabis-induced psychotic disorder (CIPD) as compared to primary psychotic disorder with concurrent cannabis abuse (PPD + CA) and also to SIPD associated with any substance.

Methods

A systematic review of SIPD literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Using strict inclusion criteria, a total of six studies examining SIPD were included in the review (two of which only considered psychosis induced by cannabis alone). The findings did not reveal many consistent differences in psychopathology. However, we did find that that compared to PPD + SA, individuals with SIPD have a weaker family history of psychotic disorder; a greater degree of insight; fewer positive symptoms and fewer negative symptoms; more depression (only in CIPD) and more anxiety.

Conclusion

There remains a striking paucity of information on the psychopathology, clinical characteristics and outcome of SIPD. Our review highlights the need for further research in this area.

Introduction

Substance abuse is common among individuals with primary psychotic disorders. Nearly half of those with a history of schizophrenia report a lifetime coexisting substance use disorder (Kavanagh et al., 2004, Regier et al., 1990). Alcohol and cannabis are the predominant substances abused by patients with psychotic disorders (Barnett et al., 2007, Kavanagh et al., 2004, Weaver et al., 2003). More recently, the use of novel psychoactive substances (NPS) has become more widespread due to their availability on the internet and in so called “head shops”. Their use appears to be significantly more common in people with psychiatric illnesses compared to healthy people (Martinotti et al., 2014). A recent systematic review on the effects of NPS on individuals with severe mental illness suggested that NPS can have a relatively severe effect on people with psychotic disorders, resulting in an exacerbation in symptoms with increased agitation, aggression and violence (Gray et al., 2016).

Multiple agents have been implicated in the development of substance-induced psychotic disorder (SIPD) including alcohol, cocaine, amphetamines and hallucinogens (Engelhard et al., 2015, Harris and Batki, 2000, Murray et al., 2013, Vardy and Kay, 1983). Much of the research however has focused on cannabis-induced psychotic disorder (CIPD). The intimate relationship between cannabis use and psychosis is well recognized (Andreasson et al., 1987, Arseneault et al., 2002, Fergusson et al., 2005, Fergusson et al., 2003, Henquet et al., 2005a, Henquet et al., 2005b, Imade and Ebie, 1991, Kristensen and Cadenhead, 2007, Kuepper et al., 2011, Semple et al., 2005, Solomons et al., 1990, van Os et al., 2002). Overall, cannabis use appears to confer a twofold risk of later schizophrenia or schizophreniform disorder (Arseneault et al., 2004).

There is still debate as to whether SIPD is a separate entity from schizophrenia and whether the diagnosis is stable over time. Some authors argue that there are no consistent differences in the symptomatology of SIPDs and primary psychotic disorders (PPDs) and that there is little evidence to support the validity of “cannabis psychosis” as a diagnostic entity (Boydell et al., 2007, Imade and Ebie, 1991, McGuire et al., 1994, Thornicroft, 1992). Others maintain that in spite of certain similarities the possibility of a nosologically distinct diagnosis remains (Basu et al., 1999).

In relation to the effect of comorbid drug use on specific symptomatology in those with psychotic disorders, varying outcomes have been reported. The most consistent finding has been that drug abusing patients with an underlying psychotic illness tend to experience fewer negative symptoms than non-drug abusing patients (Baeza et al., 2009, Baldacchino et al., 2009, Bersani et al., 2002, Buckley et al., 1994, Compton et al., 2004, Dixon et al., 1991, Dubertret et al., 2006, Swartz et al., 2006). However, several studies have noted no difference in negative symptomatology (Addington and Addington, 2007, Barrowclough et al., 2015, Grech et al., 2005, Kamali et al., 2009, Katz et al., 2010). More positive symptoms of schizophrenia are generally observed in patients with drug abuse (Addington and Addington, 2007, Allebeck et al., 1993, Baeza et al., 2009, Baldacchino et al., 2009, Bersani et al., 2002, Buhler et al., 2002, Dubertret et al., 2006, Grech et al., 2005, Kamali et al., 2009, Katz et al., 2010, Swartz et al., 2006). But once again discrepancies exist, with some studies reporting fewer or no difference in incidence of positive symptoms (Barrowclough et al., 2015, Buckley et al., 1994, Compton et al., 2004, Dixon et al., 1991).

Aggarwal et al. (2012) determined that the incidence of patients presenting with SIPD to an Indian Drug De-addiction and Treatment Centre over a 13-year period was 1.4%. Over an average follow up of 6 months, 20.3% of patients had a change in diagnosis to either schizophrenia or affective psychosis. Arendt et al. (2005) found that of 535 individuals who were initially treated for CIPD and followed up for at least three years, 238 (44.5%) later developed a schizophrenia-spectrum disorder. According to Chen et al. (2015) who observed 284 Taiwanese patients with SIPD over a 15 year period, the progression time from transient to permanent psychotic disorder was 2.2 years with the majority of transformations occurring in the first year after diagnosis. Patients who receive an initial diagnosis of PPD in the context of substance abuse have more diagnostic stability and are more likely than SIPD patients to retain their diagnosis over time (Singal et al., 2015).

Given that the diagnosis has significant implications for future management, it is important to correctly identify SIPD. If psychotic symptoms can be attributed to drug use rather than to a PPD then antipsychotic treatment can be seen as a short term option with the main emphasis being placed on substance abuse treatment.

The fourth edition of the Diagnostic and Statistical manual of Mental Disorders (DSM-IV) introduced the term SIPD in 1994 (American Psychiatric Association. and American Psychiatric Association. Task Force on DSM-IV., 1994). It was intended to distinguish substance-induced psychotic states from primary psychotic disorders. In the DSM-5, the diagnostic criteria for SIPD essentially remain unchanged (American Psychiatric Association. and American Psychiatric Association. DSM-5 Task Force., 2013). They require the presence of hallucinations and /or delusions that arise during or soon after substance intoxication or withdrawal, that are judged to be due to the physiological effects of the substance, and are not better accounted for by a primary psychotic disorder. The symptoms cannot occur exclusively during the course of a delirium and must cause significant distress or impairment.

In clinical practice, distinguishing between SIPDs and PPDs with concurrent substance use remains a diagnostic difficulty (Schanzer et al., 2006). There has been criticism of the DSM diagnostic criteria (Mathias et al., 2008, Rounsaville, 2007). A diagnosis of SIPD is based on the assumption that most of the symptoms are transient and disappear after sustained abstinence. In practice, individuals who have an established pattern of abusing substances may not report any sustained drug-free periods. Therefore, psychotic symptoms which appear during periods of heavy drug use may indeed be substance-induced, but they may also be manifestations of an underlying PPD.

Regardless of the pathophysiology, patients with psychotic illness who abuse substances are a complex group of individuals with multiple different needs. Severe mental illness and co-morbid substance misuse is associated with a range of negative outcomes including non-adherence, increased relapse and more frequent hospitalisations (Caspari, 1999, Caton et al., 2000, Zammit et al., 2008).

To our knowledge no previous systematic reviews have examined the specific psychopathology of individuals presenting with a DSM diagnosis of SIPD. There is a remarkable paucity of research in this area. We identified only one major systematic review examining the specific psychopathology of “cannabis psychosis” compared to other psychotic disorders (Baldacchino et al., 2012). However, this study used a very broad definition of “cannabis psychosis” and only included studies conducted in an inpatient setting.

Section snippets

Aim

The aim of this review was to determine if SIPD is distinct from primary psychotic disorder with concurrent substance abuse (PPD + SA), in relation to psychopathology. Furthermore we aimed to examine the specific clinical features of CIPD as compared to primary psychotic disorder with concurrent cannabis abuse (PPD + CA) and also to SIPD associated with any substance.

Objectives

The objectives of this paper were to review the demographics, general psychopathology, positive and negative symptoms, insight and

Methods

We identified studies examining SIPD associated either with any substance use or with cannabis alone. The former included studies that did not differentiate between illicit drugs, instead examining more than one type of substance within the same study. Studies investigating SIPD associated with a single substance of abuse other than cannabis were not included in the review due to the methodological difficulties in meaningfully comparing outcomes between these trials. Therefore two types of

Search results

We considered the abstracts of 671 articles identified through database searching (Fig. 1). Of these, the full text of 133 articles were reviewed together with 64 articles sourced from hand-searching references. In total, 41 studies examining SIPD were identified. Six of these studies met the full criteria for inclusion and data extraction: four investigated SIPD associated with any substance, (Caton et al., 2005, Dawe et al., 2011, Fraser et al., 2012, Weibell et al., 2013) and two examined

Discussion

We completed a comprehensive systematic review of the literature in an attempt to establish if SIPD is a distinct clinical entity from PPD + SA, particularly in relation to psychopathology. We also examined the specific clinical features of CIPD as compared to PPD + CA and to SIPD associated with any substance. Using stringent inclusion criteria we only considered six studies in the systematic review. The findings did not reveal many consistent differences in psychopathology. However, we did find

Role of funding source

No funding source.

Contributors

Lorna Wilson and Angela Kearney designed the search criteria and undertook the literature searches under the supervision of Mary Clarke. Lorna Wilson and Attila Szigeti reviewed articles for inclusion in the systematic review. The first draft of the manuscript was written by Lorna Wilson and Mary Clarke. All authors contributed to and have approved the final manuscript.

Conflict of interest

The authors report no conflict of interest.

Acknowledgement

We would like to acknowledge Carla Senf and Daria Brennan, from the St John of God Hospital Library Service, for their assistance in sourcing articles included in this review.

References (89)

  • G. Katz et al.

    Cannabis abuse and severity of psychotic and affective disorders in Israeli psychiatric inpatients

    Compr. Psychiatry

    (2010)
  • D.J. Kavanagh et al.

    Demographic and clinical correlates of comorbid substance use disorders in psychosis: multivariate analyses from an epidemiological sample

    Schizophr. Res.

    (2004)
  • K.E. Kerfoot et al.

    Substance use and schizophrenia: adverse correlates in the CATIE study sample

    Schizophr. Res.

    (2011)
  • K. Kristensen et al.

    Cannabis abuse and risk for psychosis in a prodromal sample

    Psychiatry Res.

    (2007)
  • P.K. McGuire et al.

    Cannabis and acute psychosis

    Schizophr. Res.

    (1994)
  • I. Morales-Munoz et al.

    Characterizing cannabis-induced psychosis: a study with prepulse inhibition of the startle reflex

    Psychiatry Res.

    (2014)
  • E.B. Rognli et al.

    Long-term risk factors for substance-induced and primary psychosis after release from prison. A longitudinal study of substance users

    Schizophr. Res.

    (2015)
  • D. Rottanburg et al.

    Cannabis-associated psychosis with hypomanic features

    Lancet

    (1982)
  • G. Rubio et al.

    Psychopathologic differences between cannabis-induced psychoses and recent-onset primary psychoses with abuse of cannabis

    Compr. Psychiatry

    (2012)
  • N.C. Stefanis et al.

    The effect of drug use on the age at onset of psychotic disorders in an Australian cohort

    Schizophr. Res.

    (2014)
  • A. Talamo et al.

    Comorbid substance-use in schizophrenia: relation to positive and negative symptoms

    Schizophr. Res.

    (2006)
  • J. Addington et al.

    Patterns, predictors and impact of substance use in early psychosis: a longitudinal study

    Acta Psychiatr. Scand.

    (2007)
  • P. Allebeck et al.

    Cannabis and schizophrenia: a longitudinal study of cases treated in Stockholm County

    Acta Psychiatr. Scand.

    (1993)
  • American Psychiatric Association., American Psychiatric Association. DSM-5 Task Force

    Diagnostic and Statistical Manual of Mental Disorders: DSM-5

    (2013)
  • American Psychiatric Association., American Psychiatric Association. Task Force on DSM-IV

    Diagnostic and Statistical Manual of Mental Disorders: DSM-IV

    (1994)
  • S. Andreasson et al.

    Schizophrenia in users and nonusers of cannabis. A longitudinal study in Stockholm County

    Acta Psychiatr. Scand.

    (1989)
  • M. Arendt et al.

    Cannabis-induced psychosis and subsequent schizophrenia-spectrum disorders: follow-up study of 535 incident cases

    Br. J. Psychiatry J. Ment. Sci.

    (2005)
  • M. Arendt et al.

    Familial predisposition for psychiatric disorder: comparison of subjects treated for cannabis-induced psychosis and schizophrenia

    Arch. Gen. Psychiatry

    (2008)
  • S. Arndt et al.

    Comorbidity of substance abuse and schizophrenia: the role of pre-morbid adjustment

    Psychol. Med.

    (1992)
  • L. Arseneault et al.

    Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study

    BMJ

    (2002)
  • L. Arseneault et al.

    Causal association between cannabis and psychosis: examination of the evidence

    Br. J. Psychiatry J. Ment. Sci.

    (2004)
  • I. Baeza et al.

    Cannabis use in children and adolescents with first episode psychosis: influence on psychopathology and short-term outcome (CAFEPS study)

    Schizophr. Res.

    (2009)
  • A. Baldacchino et al.

    Drugs and psychosis project: a multi-centre European study on comorbidity

    Drug Alcohol Rev.

    (2009)
  • A. Baldacchino et al.

    Cannabis psychosis: examining the evidence for a distinctive psychopathology in a systematic and narrative review

    Am. J. Addict.

    (2012)
  • J.H. Barnett et al.

    Substance use in a population-based clinic sample of people with first-episode psychosis

    Br. J. Psychiatry J. Ment. Sci.

    (2007)
  • C. Barrowclough et al.

    The impact of cannabis use on clinical outcomes in recent onset psychosis

    Schizophr. Bull.

    (2015)
  • D. Basu et al.

    Cannabis psychosis and acute schizophrenia. A case-control study from India

    Eur. Addict. Res.

    (1999)
  • G. Bersani et al.

    Cannabis and schizophrenia: impact on onset, course, psychopathology and outcomes

    Eur. Arch. Psychiatry Clin. Neurosci.

    (2002)
  • P. Buckley et al.

    Substance abuse among patients with treatment-resistant schizophrenia: characteristics and implications for clozapine therapy

    Am. J. Psychiatry

    (1994)
  • R. Cantwell

    Substance use and schizophrenia: effects on symptoms, social functioning and service use

    Br. J. Psychiatry J. Ment. Sci.

    (2003)
  • D. Caspari

    Cannabis and schizophrenia: results of a follow-up study

    Eur. Arch. Psychiatry Clin. Neurosci.

    (1999)
  • C.L. Caton et al.

    When acute-stage psychosis and substance use co-occur: differentiating substance-induced and primary psychotic disorders

    J. Psychiatr. Pract.

    (2000)
  • C.L.M. Caton et al.

    Differences between early-phase primary psychotic disorders with concurrent substance use and substance-induced psychoses

    Arch. Gen. Psychiatry

    (2005)
  • R. Chakraborty et al.

    Impact of substance use disorder on presentation and short-term course of schizophrenia

    Psychiatry J.

    (2014)
  • Cited by (38)

    • Substance use and common contributors to morbidity: A genetics perspective

      2022, eBioMedicine
      Citation Excerpt :

      Different substances have different disorder liability (i.e., the proportion of individuals who develop a SUD when they use substances), yet overall, SUDs tend to be underdiagnosed, and therefore, are undertreated,20 further perpetuating the chronicity of the illness. SUDs clinically present comorbidly with other psychiatric disorders,21–23 often further complicating the course of these illnesses. Beyond the brain, SUDs and problematic substance use also have widespread effects on other organ systems.24

    • When the law influences medical practice: Potential impact of the Bouchard-Lebrun ruling on the forensic unit of the Malartic Psychiatric Hospital in Northern Quebec, Canada

      2021, International Journal of Law and Psychiatry
      Citation Excerpt :

      From a clinical perspective, diagnoses are based on a person's current presentation and it is not necessary to determine the exact cause of a psychotic illness before undertaking treatment. Moreover, differentiating a substance-induced psychotic disorder from an endogenous illness can be extremely challenging (Carroll, McSherry, Wood, & Yannoulidis, 2008; Caton et al., 2005; Crebbin, Mitford, Paxton, & Turkington, 2009; Ghose, 2018; Rounsaville, 2007; Starzer, Nordentoft, & Hjorthøj, 2018; Wilson, Szigeti, Kearney, & Clarke, 2018). Under the Criminal Code of Canada, however, mental illness is defined as a “disease of the mind” and the aim of the juridical process is to determine whether offending behavior is the result of an inherent dysfunction of the mind or rather the consequence of the voluntary ingestion of a substance.

    • Differential effects of cannabis exposure during early versus later adolescence on the expression of psychosis in homeless and precariously housed adults

      2021, Progress in Neuro-Psychopharmacology and Biological Psychiatry
      Citation Excerpt :

      In a sub-analysis which included only individuals with a psychotic disorder, the later first use group had significantly greater negative symptoms, likely reflecting the greater proportion of subjects with schizophrenia or schizoaffective disorder. Comparisons of primary psychotic disorders with substance induced psychosis commonly demonstrate that the former are associated with more pronounced negative symptoms (Alexander et al., 2019; McKetin et al., 2016; Panenka et al., 2013), but the severity of positive symptoms is similar (Lecomte et al., 2013; Medhus et al., 2013; Wilson et al., 2018). The two groups also did not differ in neurocognitive function.

    View all citing articles on Scopus
    View full text