Psychotic disorders can account for some of the most well-known, infamous, and misunderstood mental health conditions. They can be debilitating for patients and scary for those who do not know how the disorders work. As complex as the conditions are, the possibility of drug addiction introduces new questions. This guide looks at the chances of a correlation between psychotic disorders and substance abuse and what treatment options exist for co-occurring conditions.
The term psychotic disorders, also known as psychosis, refers to a group of mental health conditions characterized by such a severe disruption to a patient’s thoughts and emotions that the patient loses the ability to perceive objective reality. When the patient experiences a psychotic episode, they will be unable to distinguish between what is real and what stimuli is the product of the psychotic disorder. The products are usually hallucinations, delusions, nonsensical speech, and other expressions of the break from normal functioning.1
A hallucination is an internal sensory perception, either visual or auditory, that is not actually present. This might involve seeing things or people that are not physically there, or hearing voices or the patient’s name being said aloud, when no such sounds were made.2 Other examples include smells or tastes that have no real source.
A delusion is a false or inaccurate belief that the patient is fixated on. In severe cases, it becomes its own condition, known as delusional disorder (but nonetheless remains an example of a psychotic disorder). The beliefs of delusional disorder are not based on reality; they are usually bizarre or very unlikely, like the patient being persecuted by aliens or government agents, followed, targeted for death, or the object of someone else’s desire (again, without any basis in reality). Common misunderstandings or experiences might be misinterpreted or exaggerated, becoming so fixed in the patient’s mind, that the person changes their behavior or lifestyle to accommodate those beliefs.3
A key factor of psychosis-induced delusions is that the patient cannot be reasoned with regarding the nature or the effects of the delusions; the patient is utterly convinced that their beliefs are real. They might interpret attempts to steer them away from the beliefs as further proof that they are being persecuted and might react violently or harmfully in self-defense.
Approximately 1.2 percent of Americans (around 3.2 million people) have schizophrenia. It can develop at any point in a person’s lifespan, but new instances are most likely to develop in early adulthood. The highest rate of diagnosis of new cases of schizophrenia tends to happen during the teenage years, reaching a peak between 16 and 25 years of age. Research has suggested that men have a “single peak of vulnerability for developing schizophrenia,” which is when they are between 18 and 25; women, on the other hand, have two peaks (one between 25 and 30, and the second when they are around 40 years old).4
Causes of schizophrenia and other related psychotic disorders can include genetics, drastic alterations to brain structure and chemical functioning, and even extreme changes to hormonal levels and sleep patterns.5 However, there is no definitive consensus on what leads to the development of these conditions. It is possible that environmental factors play a key role in determining the chances of a person exhibiting schizophrenic symptoms; for example, exposure to certain viral infections in utero might raise the possibility of the necessary brain changes occurring.6 Insufficient maternal nutrition during the first six months of pregnancy has also been floated as a theoretical risk factor for the development of schizophrenia later in life, but no conclusive scientific study has addressed this.
Other research has found that taking certain psychoactive drugs (like methamphetamines) or psychotropic drugs (such as LSD), can create a biological vulnerability that creates the possibility of brain changes associated with schizophrenia. Mental Health Daily cautions that LSD does not cause schizophrenia, but among people who do meet the other criteria for possibly developing schizophrenia, taking LSD strongly tips the scales towards making it very likely that those people will eventually start to exhibit psychotic symptoms.7
The age during which substance abuse is active may also correlate with the development of psychotic disorders. Since the human brain is still in formation as late as the early 20s, exposing the brain to psychoactive substances can influence that formation. By the mid- to late-20s, the brain has mostly finished its development, so it is unlikely that drug consumption will change the structure and functioning to the brain, to the point where a psychotic disorder can take hold (although this might still be the case if the drug consumption is chronic and extreme). However, most research on drug abuse and mental health has shown that the earlier someone starts abusing substances, the more likely it is that they will develop some form of mental health condition, such as psychosis, even years or decades after they first started.8
Other symptoms of schizophrenia and related psychotic disorders include disorganized thinking and speech, where the patient is unable to arrange their thoughts and words into coherent expressions (a symptom known as word salad). This involves very disorganized and abnormal movement of the body and the limbs, resembling anything from flailing around to unpredictable physical agitation, making it hard for the patient to complete even basic tasks, like sitting down. “Negative symptoms,” an inability to function normally, are also common. Patients with negative symptoms may neglect personal sanitation or hygiene; they may not make eye contact, change their facial expressions, or speak with any modulation in their voice.910
Other forms of psychotic disorders include psychotic disorder due to another medical condition, where the hallucinations or delusions are induced by the physiologic effects of a medical condition or operation. For example, a temporal lobe epilepsy (a chronic nervous system disorder, characterized by recurring and unpredictable seizures in the temporal lobe of the brain) have been known to cause psychotic behavior and hallucinations based on smell. Similarly, hemispatial neglect syndrome (a common condition that usually follows brain damage that impacts the right hemisphere of the brain) can also lead to the development of psychotic symptoms.111213
Tumors and infections of the central nervous systems, strokes, and migraines can also be medical disorders that elevate the risk of psychosis.14 Treating the original medical condition usually helps to reduce the severity of the psychosis symptoms, but specific treatment to address the psychosis itself will likely be required.
Another form of psychosis substance and/or medication-induced psychotic disorder, which presents as the typical psychosis symptoms, as the direct result of a psychoactive substance, or as withdrawal from such a substance. Merck Manuals notes that there are many kinds of drugs that can have this effect (everything from alcohol and amphetamines to cannabis and cocaine), although these substances are unlikely to immediately trigger psychotic symptoms. However, prolonged exposure to the drugs, in the presence of other risk factors, will significantly increase the chances that the brain changes in such a way that the patient will start exhibiting the characteristics of psychosis.15
In order for this form of psychosis to be accurately diagnosed, the delusional and hallucination symptoms should be more than those that would normally be expected of simply being on the particular drug or withdrawing from it.
The symptoms of substance- or medication-induced psychotic disorder are likely brief in duration. They resolve after the initial drug is discontinued. However, the psychosis induced by stimulants such as amphetamines and cocaine, and even dissociative drugs like PCP, will last for weeks at a time.16 The abuse of strong stimulants comes with some characteristic psychotic symptoms that are rarely found in other presentations of the condition; methamphetamine use, for example, is known to make users feel like there are insects crawling on and under their skin.17 Psychology Today writes of “binge cocaine use,” where users take cocaine many times, at increasingly higher doses, in a short time period; not only does this put the heart at extreme risk for failure, the violent stimulation of the central nervous system can cause immediate paranoid psychosis, where the user is completely unable to distinguish between auditory hallucinations and objective reality.18
Is there a correlation between psychotic disorders and substance abuse? Much debate surrounds the question over the nature of the relationship between illicit drug use, the effects on the brain, and what those effects have on how a user perceives reality. For people with the risk factors for psychotic disorders, drug use habits tend to establish themselves before the development of psychotic symptoms; most of the time, this can be as little as a month before the first breaks with reality take place.19 Given the relatively brief time period between substance use and the first signs of a psychotic disorder, some researchers have theorized that there might be a causal relationship between general psychotic disorders and the abuse of illicit drugs, but this is not a settled question.20
Psychiatric Times notes the difficulty in determining whether people who are at risk for developing psychotic disorders abuse drugs as a way of self-medicating their first symptoms, or whether the use of drugs and alcohol is the result of factors that are not connected to psychosis. Drug abuse that takes place before the development of psychotic symptoms might suggest the presence of other risk factors, which are connected with behavioral and lifestyle changes that occur when the slide into psychosis starts to manifest, and these changes may also be related to increased levels of drug or alcohol abuse.
Overall, there are two principal theories regarding the correlation between psychotic disorders and substance abuse.
This was tested in a study conducted in 2001, the results of which were published in the American Journal of Epidemiology. Researchers determined that cannabis users who “displayed a vulnerability to psychotic disorders” at the beginning of the study had a higher chance of going through isolated symptoms of psychotic disorder after their use than users who had no such vulnerability. Furthermore, just the use of cannabis led to an increased chance of isolated psychotic symptoms after the study.21
Another study, this one published in the Psychopathology journal in 2006, revealed higher-than-average reports of psychotic experiences from cannabis use in patients with an “elevated propensity towards psychosis.” The information suggests that marijuana use might activate an otherwise-dormant vulnerability toward isolated symptoms of psychotic disorder, although the mechanism by which this happens is still unknown. As explained by Dr. Nora Volkow, the director of the National Institute for Drug Abuse at the National Institutes of Health, there is no question that “marijuana can make some people temporarily experience psychotic symptoms,” but there is not yet a clear answer on whether cannabis alone can trigger schizophrenia or related conditions and symptoms.22
There is an important distinction to make between substances like marijuana or methamphetamine causing isolated psychotic symptoms, such as delusions and hallucinations, and psychosis. As “distressing” as those symptoms are, they usually wear off in most users, and a doctor would be unlikely to return a diagnosis of schizophrenia or another psychotic disorder based on that experience alone.
However, other doctors and researched remain convinced that marijuana use is a key factor in the development of psychotic disorders. NPR noted the existence of eight clinical studies, “following hundreds to thousands of people for decades,” that have suggested that cannabis use correlates with schizophrenia and other psychotic disorders.23 This has put the National Institutes of Health in the unlikely position of defending marijuana. Dr. Volkow points out that the body of research does not prove that marijuana simply causes schizophrenia, only that people with schizophrenia tend to smoke marijuana, possibly as a way of self-medicating their symptoms). The psychosis itself might be the trigger that makes people want to use cannabis and not the other way around.
Ultimately, said Dr. Volkow, what is beyond question is that if a patient with a vulnerability to schizophrenia uses cannabis, that behavior will likely activate the genes that induce psychotic episodes. A study published in Biological Psychiatry found that the combination of genetic factors and substance abuse increases the risk of developing schizophrenia sixfold.24 For someone who doesn’t have those genes, “you can smoke all the marijuana you want, and it will make no difference” to the development of psychotic disorders, although there are many other health risks to marijuana consumption.
In most cases of psychotic disorders brought about by substance abuse, discontinuing the substance and giving the patient an antipsychotic drug (such as clozapine, quetiapine, or asenapine, among other options) will help them manage both the substance abuse cravings and withdrawal symptoms, and the symptoms of the psychosis (specifically, the hallucinations and disorganized thinking). This is most effectively used when patients abuse drugs that interfere with the production and reabsorption of the dopamine neurotransmitter.25 The medications can be administered for short-term use, or they may be prescribed for the long-term to ease psychotic symptoms in patients who have the genetic risk for developing the disorder.
The choice of various forms of antipsychotic medications (typical or atypical) depends in large part on whether the patient has a vulnerability toward developing psychotic disorders, or if the symptoms of psychosis are a direct result of the substance abuse and nothing else.26
Psychosis as the result of hallucinogenic drugs like LSD requires a lot of rest and quiet observation. Medication might not be necessary.
Outside of medication, patients suffering from substance abuse and psychotic symptoms will likely require an intensive course of counseling to address the mental health fallout of the co-occurring conditions. This can entail individual sessions as well as group and family therapy. Even after formal therapy has concluded, the person is best advised to continue receiving aftercare support in the form of peer-led groups, to continue to keep the substance abuse cravings and the possible psychotic symptoms under control.