[Downloaded free from http://www.indianjpsychiatry.org on Friday, October 4, 2019, IP: 220.225.126.

138]

AWARD PAPER (KRIPAL SINGH AWARD 2015)

The study of primary psychotic disorders with concurrent substance abuse

in terms of their diagnostic stability
Ankit Singal, P. S. Bhat1, K. Srivastava2, Jyoti Prakash3
Psychiatrist, Military Hospital, Meerut, Uttar Pradesh, 1Professor & Head Psychiatry, INHS Asvini, Mumbai, 2Scientist F &
Clinical Psychologist, Armed Forces Medical College, Pune, Maharashtra, 3Professor & Head Psychiatry, Command Hospital
Eastern Command, Kolkata, West Bengal, India

ABSTRACT

Background: Co‑morbid substance use is common among individuals presenting with symptoms of psychosis. There
is a paucity of research in this area.
Aim: To study the longitudinal follow‑up of patients over 1‑year of first episode psychosis with concurrent substance
use in terms of their diagnostic stability.
Materials and Methods: Fifty patients having at least one symptom of psychosis at first admission at a General
Hospital Psychiatric Unit along with concurrent substance abuse were included and followed up for 1‑year. International
Classification of Disease‑10, diagnostic criteria were used for diagnosis. Semi‑structured sociodemographic performa
to assess the sociodemographic profile. Brief Psychiatric Rating Scale and Alcohol Use Disorder Identification Test as
rating scales were used for the assessment at 6 and 12 months.
Results: Of 50 patients, 31 patients who had a diagnosis of primary psychosis retained their diagnosis at follow‑up.
The mean age of cases in substance‑induced psychosis group was 37.47 years, which was significantly higher than
in primary psychosis group at 31.52 years. However, 7 patients of the substance‑induced psychosis group required
a change in diagnosis to primary psychosis group. The primary psychosis group patients were significantly younger,
less educated, had less family support, had greater family mental illness, had more severe symptoms, and less
hallucinations.
Conclusion: The present study is a forerunner in this area. Salient differences indicated in the study can help in
differentiating the diagnosis and in the management of cases. This is particularly relevant in the management setting
and for long‑term intervention purpose.

Key words: Diagnostic stability, psychosis, substance‑induced psychosis

INTRODUCTION health service systems. The association between substance

use and psychotic symptoms, however, is not simply due to
The widespread abuse of substances with psycho‑mimetic substance‑induced psychosis. The rate of substance abuse
properties has produced neuropsychiatric disorders that among people with severe mental illness far exceeds that in
place new demands on the substance abuse and mental the general population, even at the first onset of psychosis.
Address for correspondence: Dr. Jyoti Prakash, One of the challenges in diagnosing substance use disorders
Command Hospital, Kolkata ‑ 700 027, West Bengal, India.
E‑mail: [email protected] This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
Access this article online others to remix, tweak, and build upon the work non-commercially, as long as the
author is credited and the new creations are licensed under the identical terms.
Quick Response Code
Website: For reprints contact: [email protected]
www.indianjpsychiatry.org

How to cite this article: Singal A, Bhat PS, Srivastava K,

DOI:
Prakash J. The study of primary psychotic disorders with
concurrent substance abuse in terms of their diagnostic
10.4103/0019-5545.166638
stability. Indian J Psychiatry 2015;57:224-8.

224 © 2015 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.indianjpsychiatry.org on Friday, October 4, 2019, IP: 220.225.126.138]

Singal, et al.: Substance use in psychotic disorders

among psychiatric patients is to distinguish symptoms that use of alcohol or other psychoactive substance within
are the result of a psychiatric illness from those resulting preceding 30 days. The patients with a head injury and
from substance abuse.[1] organic psychotic disorder were excluded.

Co‑morbid substance use is common among individuals A specially designed semi‑structured sociodemographic
presenting with symptoms of psychosis.[2] Some studies Performa was used to obtain demographic, family, and
have reported this observation in nearly half of admissions clinical data. Brief Psychiatric Rating Scale (BPRS)[12] was
in a psychiatric emergency set up.[3,4] With greater awareness used for evaluating psychiatric symptoms and Alcohol
in the community and availability of effective treatment Use Disorder Identification Test (AUDIT)[13] questionnaires
options, more and more people are being referred at an was used to evaluate alcohol use at baseline, at 6 months,
early stage of psychosis. Moreover, diagnostic certainty and at 1‑year. Laboratory evaluation of substance use and
in early phase psychosis is often difficult to attain[5] and is urine drug screen for opioids, amphetamines, cannabis,
further challenged when it occurs with the co‑morbid use of benzodiazepines, and cocaine was also done at these
alcohol and other drugs.[6] Diagnostic change over time has points.
been observed in longitudinal studies of primary psychiatric
disorders.[7] A total of 50 patients entered the study. The diagnosis was
made by an independent evaluation by two psychiatrists
International Classification of Disease (ICD) classificatory using ICD‑10. Diagnostic stability was defined as having the
system gives a separate nosological status to same category (primary or substance‑induced psychosis)
substance‑induced psychosis, and hence, a need to at baseline and at follow‑ups. The diagnostic change
differentiate it from primary psychotic disorders in the was defined as a change of diagnosis from the baseline
absence of organic damage. A change in diagnosis from substance‑induced psychosis to the primary psychosis
a substance‑induced psychosis to a primary psychosis or from the primary psychosis to the substance‑induced
can reflect the progression of an illness or defective psychosis at either the 6 months or at 12 months follow‑ups.
diagnostic assessments. Psycho‑active drugs may Subjects with primary psychosis were compared to those
precipitate schizophrenia‑like illness[8,9] or may develop with substance‑induced psychosis on the demographic,
into a chronic psychotic disorder over time.[10] In fact, family, clinical, and social domains. The group differences
Diagnostic and Statistical Manual of Mental Disorders, were tested using either Chi‑square, two‑tailed, unpaired
Fifth Edition research agenda has included this substance t‑tests, or others depending on the type of variable.
abuse/psychosis co‑morbidity as an important area for
research.[11] RESULTS

The distinction between a substance‑induced psychosis and Of the 50 cases, during the study, 31 cases were diagnosed
a primary psychotic disorder is an important because they with primary psychosis and 19 cases were diagnosed with
require fundamentally different approaches to treatment. substance‑induced psychosis. After initial management, all
Despite this, very little is known about longitudinal were placed on medications and followed monthly. Primary
diagnostic stability and change in early phase psychosis Psychosis group had 14 cases of schizophrenia, 9 cases of
co‑occurring with psychoactive substance use. Hence, the depression with psychosis, 4 cases of unspecified psychosis,
present study was planned to evaluate the diagnostic stability 2 cases of persistent delusional, and 2 cases of mania with
over a period of 1‑year and to analyze the differences in key psychosis, whereas substance‑induced psychosis group
demographic, family, clinical, and laboratory parameters had 16 cases of alcohol‑induced psychosis and 3 cases of
between the two groups. cannabis‑induced psychosis.

MATERIALS AND METHODS The mean age, socioeconomic background, and family
history in both primary and substance‑induced psychotic
This study was carried out in a General Hospital Psychiatry disorder is as brought out in Table 1. The majority of
Unit of a large hospital at Pune. All consecutive cases cases (89%) in substance‑induced psychosis group had an
presenting with first episode psychosis (FEP) and concurrent education till higher secondary as compared to 64% in
substance abuse admitted between January 1, 2010 and primary psychosis group. Forty‑two percent of cases
June 30, 2011 were taken into this study. Subjects were in in substance‑induced psychosis group had poor family
the age range of 18–45 years of age and were English or support as compared to 29% cases in primary psychosis
Hindi speaking. group. The most common substance of abuse was alcohol
in 80% cases and the rest had used cannabis. Distribution
Informed consent was taken and Ethical Committee of auditory and visual hallucination in both primary and
approval was taken. Inclusion criteria were the presence substance‑induced psychotic disorder is as brought out
of at least one psychotic symptom during admission and in Table 2. Only 25% cases in primary psychosis group

Indian Journal of Psychiatry 57(3), Jul-Sep 2015 225

[Downloaded free from http://www.indianjpsychiatry.org on Friday, October 4, 2019, IP: 220.225.126.138]

Singal, et al.: Substance use in psychotic disorders

had suicidal ideations in comparison to 50% in the However, by the end of study follow‑up, of the 19 cases of
substance‑induced group. Substance‑induced psychotic disorders, 7 (36%) required a
change of diagnosis to primary psychosis, 5 at 6 months,
The severity of psychopathology (BPRS) and alcohol use and another 2 at the end of 1‑year. All of these cases had a
(AUDIT) in both primary and substance‑induced psychotic baseline diagnosis of alcohol‑induced psychosis. The revised
disorder is as brought out in Table 3. diagnosis was schizophrenia in 5 cases and persistent
delusional disorder in 2 cases.
All 31 cases of primary psychosis at baseline retained their
diagnostic status at 6 months and 12 months follow‑ups. DISCUSSION

Table 1: Distribution of demographic variables in primary The mean age of the cases in primary psychosis group
psychotic and substance‑induced psychotic disorder was 31.52 years, whereas it was significantly higher in the
Parameters Primary Substance- Z P substance‑induced psychotic group at 37.47 years. Caton
psychotic induced psychotic et al.[14] in their study of 2005 reported that the mean age
disorder (n=31) disorder (n=19) of cases in primary psychosis was 25 years as compared to
Mean age±SD (years) 31.52±6.76 37.47±7.50 2.83 <0.01 (S) 29 years in substance‑induced psychosis.
Socioeconomic
background n (%)
Rural 15 (48.3) 16 (84.2) 6.88 <0.05 (S) The majority of cases (89%) in substance‑induced psychosis
Urban 14 (45.1) 2 (10.5) group had an education till higher secondary as compared
Sub‑urban 2 (7.6) 1 (4.3) to 64% in primary psychosis group. This finding suggests
Family history n (%) that the cases of primary psychosis group probably had
Present 6 (19.4) 2 (10.5) 0.68 >0.05 (NS)
problems even during the education leading to less years of
Absent 25 (80.6) 17 (89.5)
formal education in this group.
S – Significant; NS – Not significant; SD – Standard deviation

Forty‑two percent of cases in substance‑induced

Table 2: Distribution of hallucinations at baseline in
psychosis group had poor family support as compared to
cases of primary psychosis, substance‑induced psychosis,
29% cases in primary psychosis group. This could be due
and change disorder
to more severe psychopathology possibly related to the
Hallucinations Primary Substance‑induced Z
psychotic psychosis (%) (n=19) n (%) P
substance abuse in the former group leading to family
disorder Stable substance‑ Change problems. However, the study by Caton et al.[14] had found
(%) (n=31) induced disorder disorder approximately equal distribution of poor family support
Auditory
among the two groups.
hallucinations
Yes 18 (58.1) 12 (100) 7 (100) 10.77 About 20% cases in primary psychosis group had a family
No 13 (41.9) 0 0 <0.005 (S) history of psychotic illness as compared to only 10% cases
Visual in the substance‑induced group indicating the importance
hallucinations
Yes 3 (10.7) 8 (66.6) 3 (42.8) 15.31
of family history in assessing the diagnosis at baseline.
No 28 (89.3) 4 (33.4) 4 (57.2) <0.0001 (S) The most common substance of abuse was alcohol in 80%
S – Significant; NS – Not significant cases and the rest had used cannabis. Alcohol use was
prevalent in 77% of cases in primary psychosis group and
Table 3: Distribution of BPRS and AUDIT score in 84% in substance‑induced psychosis group. A systematic
primary and substance‑induced disorder groups review by Archie and Gyömörey[15] in 2009 showed that at
Scales Primary Substance‑ Z P baseline, substance use disorder occurred in up to 53% of
psychotic induced psychotic FEP patients. The most common types of substance use
disorder disorder group disorder were alcohol and cannabis. Poly‑substance misuse
group (n=31) (n=19) was uncommon ranging from 1.5% to 2.5%.
BPRS score
(mean±SD)
All the cases of substance‑induced psychosis had auditory
Baseline 57.42±6.51 45.6±12.7 3.78 <0.001 (S)
6 months 45.35±6.65 33.1±12.50 3.96 <0.001 (S)
hallucinations in comparison to 58% cases in the primary
12 months 35.35±8.44 27.5±12 2.48 <0.05 (S) psychosis group and similar results were found when
AUDIT at comparing the presence of visual hallucinations. Caton[14]
baseline n (%) had also reported visual hallucination to be more common
<8 22 (71) 6 (31.5) Fisher exact
in the substance‑induced group (23.7% vs. 14.7%).
8-13 9 (29) 8 (42.1) P=0.0019 (S)
More than 13 0 (0) 5 (26.4)
S – Significant; NS – Not significant; SD – Standard deviation; BPRS – Brief
Considering the presence of suicidal ideations among
psychiatric rating scale; AUDIT – Alcohol use disorder identification test the groups, only 25% cases in primary psychosis group

226 Indian Journal of Psychiatry 57(3), Jul-Sep 2015

[Downloaded free from http://www.indianjpsychiatry.org on Friday, October 4, 2019, IP: 220.225.126.138]

Singal, et al.: Substance use in psychotic disorders

had suicidal ideations in comparison to 50% in the with a longer follow‑up is recommended to be conducted
substance‑induced group. However, the primary psychosis for robust evidence of understanding of the stability of
group had more severe symptoms and the severity was FEP with concurrent substance use.
more at all the points of assessment. Similar finding has
been reported by Caton et al.[16] CONCLUSION

Comparing the AUDIT scores to identify substance use/ The present study is one of the few studies carried out
abuse, 68% cases in substance‑induced psychosis group especially in reference with diagnostic stability. It is
had alcohol use suggestive of abuse/or dependence pertinent to mention that differential diagnosis between
as compared to 29% cases in the primary psychosis a primary and a substance‑induced psychotic disorder at
group. Alcohol dependence was predictive of psychotic baseline is important from the clinical, prognostic, and
experience in a general adult population survey in Great follow‑up perspectives. Our research found out a significant
Britain.[17] It reported two‑fold higher risk independent of difference in clinic‑psycho‑social paradigm between the
other risk factors for psychotic symptoms, suggesting that primary psychotic disorder group and substance‑induced
alcohol dependence per se doubles the risk of psychotic psychotic disorder group. The primary psychotic disorders
symptoms. group is relatively stable over time, but the diagnosis in
substance‑induced psychotic disorders group changed over
Similar findings have been reported by Caton et al.[14] time. These have a significant therapeutic connotation and
when they assessed 400 participants are presenting with needs to be kept in mind.
first psychotic episode concurrent with substance use.
Their sample was taken from five psychiatric emergency Financial support and sponsorship
departments. The study reported that 44% participants Nil.
were diagnosed with substance‑induced psychosis. The
analysis identified three key predictors as being greater Conflicts of interest
in participants of the substance‑induced psychotic There are no conflicts of interest.
group: Parental substance abuse, diagnosis of any drug
dependence, and visual hallucinations. REFERENCES

At 1‑year follow‑up, 37% of the substance‑induced 1. Ling  W, Compton  P, Rawson  R, Wesson  DR. Neuropsychiatry of
alcohol and drug abuse. In: Schiffer  RB, Rao  SM, Fogel  BS, editors.
psychotic disorder had converted to primary psychosis. Neuropsychiatry. 2nd ed. Baltimore, MD: Lippincott, Williams and Wilkins;
Aggarwal et al.[17] found the change of diagnosis to be 20% 2003. p. 893‑933.
in their retrospective study on Indian substance‑induced 2. Barnes  TR, Mutsatsa  SH, Hutton  SB, Watt  HC, Joyce  EM. Comorbid
substance use and age at onset of schizophrenia. Br J Psychiatry
psychotic disorder sample. Johns et al.[18] in their study 2006;188:237‑42.
found that 11% cases required a change in diagnosis. 3. Green B, Young R, Kavanagh D. Cannabis use and misuse prevalence
among people with psychosis. Br J Psychiatry 2005;187:306‑13.
On comparison of the characteristics of the participants 4. Mauri  MC, Volonteri  LS, De Gaspari  IF, Colasanti  A, Brambilla  MA,
in the change disorder group with primary psychosis Cerruti  L. Substance abuse in first‑episode schizophrenic patients: A
group, the change disorder group had lower scores on retrospective study. Clin Pract Epidemiol Ment Health 2006;2:4.
5. Drake RJ, Dunn G, Tarrier N, Haddock G, Haley C, Lewis S. The evolution
baseline psychopathology and more suicidal ideations. of symptoms in the early course of non‑affective psychosis. Schizophr Res
When the change group was compared to stable 2003;63:171‑9.
6. Grech A, Van Os J, Jones PB, Lewis SW, Murray RM. Cannabis use and
substance‑induced psychotic disorder group parental outcome of recent onset psychosis. Eur Psychiatry 2005;20:349‑53.
mental illness was found more in change group. Reasons 7. Schwartz  JE, Fennig  S, Tanenberg‑Karant  M, Carlson  G, Craig  T,
for a change from substance‑induced psychotic disorder Galambos N, et al. Congruence of diagnoses 2 years after a first‑admission
diagnosis of psychosis. Arch Gen Psychiatry 2000;57:593‑600.
to a primary psychotic disorder over time might be 8. Zammit S, Allebeck P, Andreasson S, Lundberg I, Lewis G. Self reported
due to few possibilities like first, there is no change cannabis use as a risk factor for schizophrenia in Swedish conscripts of
1969: Historical cohort study. BMJ 2002;325:1199.
in diagnostic status over time and cases diagnosed as 9. Semple  DM, McIntosh  AM, Lawrie  SM. Cannabis as risk factor for
substance‑induced psychosis at baseline might have psychosis: Systemic review. J Psychopharmacol 2005;19:187‑94.
been primary psychotic disorder at baseline but due to 10. Mc Lellan  AT, Woody  GE, O’Brien  CP. Development of psychiatric
illness in drug abusers. Possible role of drug preference. N Engl J Med
cross‑sectional assessment diagnosis might have been 1979;301:1310‑4.
missed and a second possibility is that substance‑induced 11. Rounsaville  BJ. DSM‑V research agenda: Substance abuse/psychosis
comorbidity. Schizophr Bull 2007;33:947‑52.
psychotic disorder might be marker for an emerging 12. Overall  JE, Gorham  DR. The Brief Psychiatric Rating Scale  (BPRS):
psychosis that was not yet manifest at first admission. A comprehensive review. J Oper Psychiatry 1991;148:472.
Such individuals might be especially vulnerable to the 13. Babor TF, De la Fuente JR, Saunders J, Grant M. AUDIT the Alcohol Use
Disorder Identification Test: Guidelines for Use in Primary Health. WHO/
psycho‑mimetic properties of the substances. The third MNH/DAT 89.4. Geneva: World Health Organisation; 1989.
possibility is that the FEP might be part of a process of 14. Caton  CL, Drake  RE, Hasin  DS, Dominguez  B, Shrout  PE, Samet  S,
et al. Differences between early‑phase primary psychotic disorders with
moving toward an autonomous psychotic disorder in concurrent substance use and substance‑induced psychoses. Arch Gen
those chronically misusing drugs. However, this study Psychiatry 2005;62:137‑45.

Indian Journal of Psychiatry 57(3), Jul-Sep 2015 227

[Downloaded free from http://www.indianjpsychiatry.org on Friday, October 4, 2019, IP: 220.225.126.138]

Singal, et al.: Substance use in psychotic disorders

15. Archie  S, Gyömörey K. First episode psychosis, substance abuse and 17. Aggarwal M, Banerjee A, Singh SM, Mattoo SK, Basu D. Substance‑induced
prognosis: A systematic review. Curr Psychiatry Rev 2009;5:153‑63. psychotic disorders: 13‑year data from a de‑addiction centre and their
16. Caton  CL, Hasin  DS, Shrout  PE, Drake  RE, Dominguez  B, First  MB, clinical implications. Asian J Psychiatr 2012;5:220‑4.
et al. Stability of early‑phase primary psychotic disorders with concurrent 18. Johns LC, Cannon M, Singleton N, Murray RM, Farrell M, Brugha T, et al.
substance use and substance‑induced psychosis. Br J Psychiatry Prevalence and correlates of self‑reported psychotic symptoms in the
2007;190:105‑11. British population. Br J Psychiatry 2004;185:298‑305.

Author Help: Online submission of the manuscripts

Articles can be submitted online from http://www.journalonweb.com. For online submission, the articles should be prepared in two files (first
page file and article file). Images should be submitted separately.
1) First Page File:
Prepare the title page, covering letter, acknowledgement etc. using a word processor program. All information related to your identity should
be included here. Use text/rtf/doc/pdf files. Do not zip the files.
2) Article File:
The main text of the article, beginning with the Abstract to References (including tables) should be in this file. Do not include any informa-
tion (such as acknowledgement, your names in page headers etc.) in this file. Use text/rtf/doc/pdf files. Do not zip the files. Limit the file
size to 1 MB. Do not incorporate images in the file. If file size is large, graphs can be submitted separately as images, without their being
incorporated in the article file. This will reduce the size of the file.
3) Images:
Submit good quality color images. Each image should be less than 4096 kb (4 MB) in size. The size of the image can be reduced by decreas-
ing the actual height and width of the images (keep up to about 6 inches and up to about 1800 x 1200 pixels). JPEG is the most suitable
file format. The image quality should be good enough to judge the scientific value of the image. For the purpose of printing, always retain a
good quality, high resolution image. This high resolution image should be sent to the editorial office at the time of sending a revised article.
4) Legends:
Legends for the figures/images should be included at the end of the article file.

228 Indian Journal of Psychiatry 57(3), Jul-Sep 2015