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DSM-IV

In DSM-IV, this disorder is called Substance-Induced Psychotic Disorder

Diagnostic Criteria

A. Prominent hallucinations or delusions. Note: Do not include hallucinations if the person has insight that they are substance induced.

B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):

  1. the symptoms in Criterion A developed during, or within a month of, Substance Intoxication or Withdrawal
  2. medication use is etiologically related to the disturbance

C. The disturbance is not better accounted for by a Psychotic Disorder that is not substance induced. Evidence that the symptoms are better accounted for by a Psychotic Disorder that is not substance induced might include the following:

  • the symptoms precede the onset of the substance use (or medication use)
  • the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use
  • there is other evidence that suggests the existence of an independent non-substance-induced Psychotic Disorder (e.g., a history of recurrent non-substance-related episodes)

D. The disturbance does not occur exclusively during the course of a delirium.

Note: This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.

Specify if:

  • With Onset During Intoxication: if criteria are met for Intoxication with the substance and the symptoms develop during the intoxication syndrome
  • With Onset During Withdrawal: if criteria are met for Withdrawal from the substance and the symptoms develop during, or shortly after, a withdrawal syndrome

Subtypes and Specifiers

Subtypes

One of the following subtypes may be used to indicate the predominant symptom presentation. If both delusions and hallucinations are present, record whichever is predominant:

With Delusions

This subtype is used if delusions are the predominant symptom.

With Hallucinations

This subtype is used if hallucinations are the predominant symptom.

Specifiers

The context of the development of the psychotic symptoms may be indicated by using one of the specifiers listed below:

With Onset During Intoxication

This specifier should be used if criteria for intoxication with the substance are met and the symptoms develop during the intoxication syndrome.

With Onset During Withdrawal

This specifier should be used if criteria for withdrawal from the substance are met and the symptoms develop during, or shortly after, a withdrawal syndrome.

Recording Procedures

The name of the Substance-Induced Psychotic Disorder begins with the specific substance (e.g., cocaine, methylphenidate, dexamethasone) that is presumed to be causing the psychotic symptoms. The name of the disorder (e.g., Cocaine-Induced Psychotic Disorder; Methylphenidate-Induced Psychotic Disorder) is followed by the subtype indicating the predominant symptom presentation and the specifier indicating the context in which the symptoms developed (e.g., Cocaine-Induced Psychotic Disorder, With Delusions, With Onset During Intoxication; Phencyclidine-Induced Psychotic Disorder, With Hallucinations, With Onset During Intoxication). When more than one substance is judged to play a significant role in the development of the psychotic symptoms, each should be listed separately. If a substance is judged to be the etiological factor, but the specific substance or class of substance is unknown, the category Unknown Substance-Induced Psychotic Disorder, With Delusions, or Unknown Substance-Induced Psychotic Disorder, With Hallucinations, may be used.

Specific Substances

Psychotic Disorder can occur in association with intoxication with the following classes of substances: alcohol; amphetamine and related substances; cannabis; cocaine; hallucinogens; inhalants; opioids (meperidine); phencyclidine and related substances; sedatives, hypnotics, and anxiolytics; and other or unknown substances. Psychotic Disorders can occur in association with withdrawal from the following classes of substances: alcohol; sedatives, hypnotics, and anxiolytics; and other or unknown substances. The initiation of the disorder may vary considerably with the substance. For example, smoking a high dose of cocaine may produce psychosis within minutes, whereas days or weeks of high-dose alcohol or sedative use may be required to produce psychosis. Hallucinations may occur in any modality. In Alcohol-Induced Psychotic Disorder, With Hallucinations, With Onset During Withdrawal, vivid, persistent, and usually unpleasant hallucinations develop shortly (within 48 hours) after cessation of or reduction in alcohol ingestion. This disorder occurs only after prolonged, heavy ingestion of alcohol in people who apparently have Alcohol Dependence. The auditory hallucinations are usually voices, but there may also be visual or tactile hallucinations.

The Psychotic Disorders induced by intoxication with amphetamine and cocaine share similar clinical features. Persecutory delusions may rapidly develop shortly after use of amphetamine or a similarly acting sympathomimetic. Distortion of body image and misperception of people's faces may occur. The hallucination of bugs or vermin crawling in or under the skin (formication) can lead to scratching and extensive skin excoriations. Cannabis-Induced Psychotic Disorder may develop shortly after cannabis use and usually involves persecutory delusions. The disorder is apparently rare. Marked anxiety, emotional lability, depersonalization, and subsequent amnesia for the episode can occur. The disorder usually remits within a day, but in some cases may persist for a few days. Hallucinations associated with Cannabis Intoxication are rare except when very high blood levels are reached.

Substance-Induced Psychotic Disorders may at times not resolve promptly when the offending agent is removed. Agents such as amphetamines, phencyclidine, and cocaine have been reported to evoke temporary psychotic states than can sometimes persist for weeks or longer despite removal of the agent and treatment with neuroleptics. These may be initially difficult to distinguish from non-substance-induced Psychotic Disorders.

Some of the medications reported to evoke psychotic symptoms include anesthetics and analgesics, anticholinergic agents, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobial medications, antiparkinsonian medications, chemotherapeutic agents (e.g., cyclosporine and procarbazine), corticosteroids, gastrointestinal medications, muscle relaxants, nonsteroidal anti-inflammatory medications, other over-the-counter medications (e.g., phenylephrine, pseudoephedrine), antidepressant medication, and disulfiram. Toxins reported to induce psychotic symptoms include anticholinesterase, organophosphate insecticides, nerve gases, carbon monoxide, carbon dioxide, and volatile substances such as fuel or paint.

Differential Diagnosis

Substance Intoxication or Withdrawal

A diagnosis of Substance-Induced Psychotic Disorder should be made instead of a diagnosis of Substance Intoxication or Substance Withdrawal only when the psychotic symptoms are judged to be in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention. Individuals intoxicated with stimulants, cannabis, the opioid meperidine, or phencyclidine, or those withdrawing from alcohol or sedatives, may experience altered perceptions (scintillating lights, sounds, visual illusions) that they recognize as drug effects. If reality testing for these experiences remains intact (i.e., the person recognizes that the perception is substance induced and neither believes in nor acts on it), the diagnosis is not Substance-Induced Psychotic Disorder. Instead, Substance Intoxication or Withdrawal, With Perceptual Disturbances, is diagnosed (e.g., Cocaine Intoxication, With Perceptual Disturbances).

Hallucinogen Persisting Perception Disorder

"Flashback" hallucinations that can occur long after the use of hallucinogens has stopped are diagnosed as Hallucinogen Persisting Perception Disorder.

Delirium

If substance-induced psychotic symptoms occur exclusively during the course of a delirium, as in some severe forms of Alcohol Withdrawal, the psychotic symptoms are considered to be an associated feature of the delirium and are not diagnosed separately.

Primary Psychotic Disorder

A Substance-Induced Psychotic Disorder is distinguished from a primary Psychotic Disorder by the fact that a substance is judged to be etiologically related to the symptoms.

Psychotic Disorder Due to a General Medical Condition

A Substance-Induced Psychotic Disorder due to a prescribed treatment for a mental or general medical condition must have its onset while the person is receiving the medication (or during withdrawal, if there is a withdrawal syndrome associated with the medication). Once the treatment is discontinued, the psychotic symptoms will usually remit within days to several weeks (depending on the half-life of the substance and the presence of a withdrawal syndrome). If symptoms persist beyond 4 weeks, other causes for the psychotic symptoms should be considered. Because individuals with general medical conditions often take medications for those conditions, the clinician must consider the possibility that the psychotic symptoms are caused by the physiological consequences of the general medical condition rather than the medication, in which case Psychotic Disorder Due to a General Medical Condition is diagnosed. The history often provides the primary basis for such a judgement. At times, a change in the treatment for the general medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically for that person whether the medication is the causative agent. If the clinician has ascertained that the disturbance is due to both a general medical condition and substance use, both diagnoses (i.e., Psychotic Disorder Due to a General Medical Condition and Substance-Induced Psychotic Disorder) may be given. When there is insufficient evidence to determine whether the psychotic symptoms are due to a substance (including medication) or to a general medical condition or are primary (i.e., not due to either a substance or a general medical condition), Psychotic Disorder Not Otherwise Specified would be indicated.

DSM-5

Diagnostic Criteria

A. Presence of one or both of the following symptoms:

  1. Delusions.
  2. Hallucinations.

B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):

  1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
  2. The involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by a psychotic disorder that is not substance/medication-induced. Such evidence of an independent psychotic disorder could include the following:

  • The symptoms preceded the onset of the substance/medication use.
  • The symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication.
  • There is other evidence evidence of an independent non-substance/medication-induced psychotic disorder (e.g., a history of recurrent non-substance/medication-related episodes).

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.

Note: If a mild substance use disorder if comorbid with the substance-induced psychotic disorder, the clinician should record "mild [substance] use disorder" before the substance-induced psychotic disorder (e.g., "mild cocaine use disorder with cocaine-induced psychotic disorder"). If a moderate or severe substance use disorder is comorbid with the substance-induced psychotic disorder, the clinician should record "moderate [substance] use disorder" or "severe [substance] use disorder," depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the clinician should record only the substance-induced psychotic disorder.

Specify if:

  • With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication.
  • With onset during withdrawal: If the criteria are met for withdrawal from with substance and the symptoms develop during, or shortly after, withdrawal.

Specify current severity:

Severity is rated by a quantitative assessment of the primary symptoms of psychosis, including delusions, hallucinations, abnormal psychomotor behavior, and negative symptoms. Each of these symptoms may be rated for its current severity (most severe in the last 7 days) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).

Note: Diagnosis of substance/medication-induced psychotic disorder can be made without using this severity specifier.

Recording Procedures

The name of the substance/medication-induced psychotic disorder begins with the specific substance (e.g., cocaine, dexamethasone) that is presumed to be causing the delusions of hallucinations. In cases in which a substance is judged to be an etiological factor but the specific class of substance is unknown, the category "unknown substance" should be used.

When recording the name of the disorder, the comorbid substance use disorder (if any) is listed first, followed by the word "with," followed by the name of the substance-induced psychotic disorder, followed by the specification of onset (i.e., onset during intoxication, onset during withdrawal). For example, in the case of delusions occurring during intoxication in a man with a severe cocaine use disorder, the diagnosis is severe cocaine use disorder with cocaine-induced psychotic disorder, with onset during intoxication. A separate diagnosis of the comorbid severe cocaine use disorder is not given. If the substance-induced psychotic disorder occurs without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance), no accompanying substance use disorder is noted (e.g., phencyclidine-induced psychotic disorder, with onset during intoxication). When more than one substance is judged to play a significant role in the development of psychotic symptoms, each should be listed separately (e.g., severe cannabis use disorder with cannabis-induced psychotic disorder, with onset during intoxication; mild phencyclidine use disorder with phencyclidine-induced psychotic disorder, with onset during intoxication).

Differential Diagnosis

Substance intoxication or substance withdrawal

Individuals intoxicated with stimulants, cannabis, the opioid meperidine, or phencyclidine, or those withdrawing from alcohol or sedatives, may experience altered perceptions that they recognize as drug effects. If reality testing for these experiences remains intact (i.e., the individual recognizes that the perception is substance induced and neither believes in nor acts on it), the diagnosis is not substance/medication-induced psychotic disorder. Instead, substance intoxication or substance withdrawal, with perceptual disturbances, is diagnosed. (e.g., cocaine intoxication, with perceptual disturbances). "Flashback" hallucinations that can occur long after the use of hallucinogens has stopped are diagnosed as hallucinogen persisting perception disorder. If substance/medication-induced psychotic symptoms occur exclusively during the course of a delirium, as in severe forms of alcohol withdrawal, the psychotic symptoms are considered to be an associated feature of the delirium and are not diagnosed separately. Delusions in the context of a major or mild neurocognitive disorder would be diagnosed as major or mild neurocognitive disorder, with behavioral disturbance.

Primary psychotic disorder

A substance/medication-induced psychotic disorder is distinguished from a primary psychotic disorder, such as schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder, other specified schizophrenia spectrum and other psychotic disorder, or unspecified schizophrenia spectrum and other psychotic disorder, by the fact that a substance is judged to be etiologically related to the symptoms.

Psychotic disorder due to another medical condition

A substance/medication-induced psychotic disorder due to a prescribed treatment for a mental or medical condition must have its onset while the individual is receiving the medication (or during withdrawal, if there is a withdrawal syndrome associated with the medication). Because individuals with medical conditions often take medications for those conditions, the clinician must consider the possibility that the psychotic symptoms are caused by the physiological consequences of the medical condition rather than the medication, in which case psychotic disorder due to another medical condition is diagnosed. The history often provides the primary basis for such a judgement. At times, a change in the treatment for the medical condition (e.g., medication substitution or discontinuation) may be needed to determine empirically for that individual whether the medication is the causative agent. If the clinician has ascertained that the disturbance is attributable to both a medical condition and substance/medication use, both diagnoses (i.e., psychotic disorder due to another medical condition and substance/medication-induced psychotic disorder) may be given.