The clinical presentation of drug-induced psychosis understands the presence of delusions and/or hallucinations [1]. Most frequent delusions are of the persecutory type, while grandiose, referential, erotomanic, nihilistic and somatic types have also been described [1]. On the other hand, an onset of vivid and clear hallucinations, either auditory (more common) or sensory, is also the main feature of psychosis [1]. The onset of symptoms significantly varies depending on the substance. For example, patients who inhale large amounts of cocaine can develop symptoms within minutes, whereas sedative-hypnotic drugs and alcohol can induce psychosis after a prolonged period of use [1] [2]. Methamphetamine and cocaine-induced psychosis typically presents with delusions of persecution and visual hallucinations that last for a short period of time, but relapses have shown to occur within one week or one month after the substance abuse [3]. A similar presentation is seen across other causes, but paranoia, distortion in the perception of time and feelings of depersonalization have been reported in patients who develop psychosis after use of hallucinogenic substances, such as cannabis or lysergic acid diethylamide (LSD) [1] [4]. Moreover, opioid intoxication is characterized by profound euphoria, while withdrawal can either lead to agitation, gastrointestinal irritation, and craving, or to depression and anhedonia [4]. Drug-induced psychosis can also occur in patients who are taking antiepileptic and antiparkinsonian drugs [5] [6], which can mislead the physician toward substance abuse.

• Turkish

  The relationship between catechol-O-methyltransferase gene Val158Met (COMT) polymorphism and premorbid cannabis use in Turkish male patients with schizophrenia. In Vivo. 2015; 29 (1):129–132. [ PubMed ] [ Google Scholar ] 31. [ncbi.nlm.nih.gov]

  Ermis A, Erkiran M, Dasdemir S, Turkcan AS, Ceylan ME, Bireller ES, Cakmakoglu B (2015) The relationship between catechol-O-methyltransferase gene Val158Met (COMT) polymorphism and premorbid cannabis use in Turkish male patients with schizophrenia. [doi.org]

• Pathologist

  A pathologist in August testified that trace amounts of acetone were found in Green’s system. “All he says is that it makes it better,” Green is heard telling a detective on the recording of the meth-and-acetone cocktail. [sacbee.com]

• Visual Hallucination

  RESULTS: A total of 157 of 160 patients had hallucinations, with visual hallucinations being the most common (97% of subjects), followed by auditory (48%), tactile (23%), and olfactory (16%). [ncbi.nlm.nih.gov]

  hallucinations, intermittent memory impairment, mutism, disturbances of body image, delusions, apathy, and hypomania. [doi.org]

  Symptoms of an antihistamine psychosis often include both auditory and visual hallucinations. [mentalhealthdaily.com]

  While some patients may be experiencing mood swings during withdrawal, and certain drug abusers could exhibit some of the telltale signs of psychosis — like visual hallucinations — it isn’t full-blown psychosis if said hallucinations are merely occurring [theoakstreatment.com]

  I had used the substance off and on for 6 years and when I decided to quit, my body put me through withdrawal symptoms including drug induced psychosis, audible/visual hallucinations, loss of appetite, and anxiety. I quite literally lost my mind. [spiceaddictionsupport.org]

• Aggressive Behavior

  Blunted affect was milder in users than in non-users, whereas hostility and aggressive behavior was significantly more severe in users than in non-users. [doi.org]

  Keywords: Ecstasy use, psychotic acute episode, aggressive behavior 1. [ncbi.nlm.nih.gov]

  Dangerously Aggressive Behavior as a Side Effect of Alprazolam. Am J Psychiatry 1989; 146: 276. Karch FE. Rage Reaction Associated with Clorazepate Dipotassium. Annals of Internal Medicine 1979; 91: 61-62. Hansson O, Tonnby B. [benzo.org.uk]

  Hinsberger and colleagues 10 described toxic effects such as slurred speech, nausea, ataxia, nystagmus, mood changes, perceptual distortions, and aggressive behavior. [primarypsychiatry.com]

• Urinary Hesitancy

  There were no significant differences between the groups in the severity of drooling, memory impairment, constipation, orthostatic lightheadedness, urinary hesitancy, confusion, headaches, fatigue, or daytime sedation. [nejm.org]

• Confusion

  Six did not (five on clozapine, one on olanzapine) because of confusion, erratic behavior, and increased hallucinations. No crossover failure had worsened PD except for increased tremor in one. [ncbi.nlm.nih.gov]

  Normally this kind of psychotic symptoms (Transient) can last for a few days until detoxing off the drug and is often characterized by delusions, memory loss, confusion and sometimes hallucinations. [thewellnessseeker.com]

  According to Barnes (2008), cannabis can cause anxiety attacks or feelings of paranoia, and using a lot of cannabis regularly, may be putting oneself at risk of suffering confusion or delusions. [ukessays.com]

  Confused thoughts result in confused speech that may not make any sense. [sovteens.com]

  Acute: During the acute, or active, phase of schizophrenia, individuals will experience hallucinations, delusions, and confusing thoughts. These symptoms are similar to those of drug-induced psychosis. [sunrisehouse.com]

• Agitation

  These symptoms, plus agitation and hostility, may ultimately be the best measure of DIP in patients with PD. [ncbi.nlm.nih.gov]

  These are some of the side effects caused by ingestion of these drugs: Agitation Hallucinations Paranoia Chest Pain Increased pulse High blood pressure Suicidal thinking and behavior Even after the drug stimulation wears off, the suicidal behavior may [cchrflorida.org]

  Upon presentation, he demonstrated echolalia, paranoia, flight of ideas, and psychomotor agitation. The patient remained agitated for the first 2 days of hospitalization. He attempted to barricade himself in his room. [doi.org]

  Reactions reported include depression, agitation, aggression, and depersonalisation (personal communication). Psychotic phenomena seem to be a rare side effect of doxazosin treatment and are not documented in standard reference books. [bmj.com]

• Irritability

  Moreover, opioid intoxication is characterized by profound euphoria, while withdrawal can either lead to agitation, gastrointestinal irritation, and craving, or to depression and anhedonia. [symptoma.com]

  Symptoms of delirium tremens include: Agitation/excitement Irritability Confusion/disorientation Delirium Sudden mood changes Fatigue or stupor Restlessness Body tremors Changes in mental functions Decreased attention span Sensitivity to light, sound, [americanaddictioncenters.org]

  DISCUSSION OTC cough and cold preparations are nearly ubiquitous, and are marketed for the relief of those most irritating symptoms of the common cold: rhinorrhea and cough. [doi.org]

  Amphetamine and methamphetamines (Speed and crystal meth) These drugs provide the user with initially an energetic feeling, along with confidence but, along with highs, there can be panic attacks, irritability and paranoia, according to Barnes (2008). [ukessays.com]

• Motor Symptoms

  The data indicate that GPi pallidotomy ameliorates the motor symptoms in patients with drug-induced psychosis (DIP), but has no significant impact on their consequent daily activities. [ncbi.nlm.nih.gov]

  Risperidone and olanzapine have been shown to worsen PD symptoms. 4,5 Quetiapine has been recently suggested as a possible treatment for PD because it reduces psychosis without worsening motor symptoms, and because its use does not require blood monitoring [neurology.org]

  There was no worsening of motor symptoms in either group according to the measures of parkinsonism ( Table 3 ). [nejm.org]

  Conversely, younger patients who undergo bariatric surgery present predominantly with sensory motor symptoms of WE and mostly do not develop mental status changes [ 38 ]. [doi.org]

• Decreased Attention Span

  Symptoms of delirium tremens include: Agitation/excitement Irritability Confusion/disorientation Delirium Sudden mood changes Fatigue or stupor Restlessness Body tremors Changes in mental functions Decreased attention span Sensitivity to light, sound, [americanaddictioncenters.org]

Current diagnostic criteria of drug-induced psychosis involve the following findings [1]:

• The onset of symptoms during or soon after an introduction of a harmful substance, or exposure to a medication that can provoke such symptoms.
• An absence of other signs and symptoms that may point to another cause, including the onset of symptoms before the use of suspected drugs, a prolonged duration of complaints (about 1 month) after cessation of use, or their presence in the setting of acute withdrawal.
• Appearance of symptoms in time not related to delirium
• Significant distress and impaired daily functioning caused by symptoms.

Once a presumptive diagnosis is made, it is necessary to determine the substance that is responsible for the development of symptoms. For this reason, an adequate and thorough patient history is considered to be the most important part of the diagnostic workup, which can reveal recent use of particular medications or substances [1] [7]. Preferably, hetero-anamnestic data should be obtained, involving both the family and friends, as the patient may often refrain from admitting substance abuse. If the cause remains undetermined, routine toxicology screening of urine for recreational drugs, alcohol testing, thyroid function tests, a basic metabolic panel and a thorough workup of the central nervous system (lumbar puncture, computed tomography of the endocranium) may be performed [2] [8].

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth Edition. Arlington, VA: American Psychiatric Publishing;2013.
2. Porter RS, Kaplan JL. Merck Manual of Diagnosis and Therapy. 19th Edition. Merck Sharp & Dohme Corp. Whitehouse Station, N.J;2011.
3. Chen Z, Lusicic A, O'Brien TJ, et al. Psychotic disorders induced by antiepileptic drugs in people with epilepsy. Brain. 2016;139(10):2668-2678
4. Paparelli A, Di Forti M, Morrison PD, Murray RM. Drug-Induced Psychosis: How to Avoid Star Gazing in Schizophrenia Research by Looking at More Obvious Sources of Light. Front Behav Neurosci. 2011;5:1.
5. Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-Occurring Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US);2005.
6. Kuzuhara S. Drug-induced psychotic symptoms in Parkinson's disease. Problems, management and dilemma. J Neurol. 2001;248(3):III28-31.
7. Grant KM, LeVan TD, Wells SM, et al. Methamphetamine-Associated Psychosis. Journal of Neuroimmune Pharmacology. 2012;7(1):113-139.
8. Algon S, Yi J, Calkins ME, Kohler C, Borgmann-Winter KE. Evaluation and Treatment of Children and Adolescents with Psychotic Symptoms. Curr Psychiatry Rep. 2012;14(2):101-110.