Acute psychosis represents one of the most severe and complex presentations, and one of the most intrusive when attempting to treat co-occurring AOD use [937]. During an acute episode of psychosis, a person’s behaviour is likely to be disruptive and/or peculiar. Symptoms of psychosis include [938]:
- Delusions – false beliefs that are held with conviction. They are often bizarre and may involve a misinterpretation of perceptions or experiences (e.g., thinking that someone is out to get you, that you have special powers, or that passages from the newspaper have special meaning for you).
- Hallucinations – false perceptions such as seeing, hearing, smelling, sensing, or tasting things that others cannot.
- Disorganised speech – illogical, disconnected, or incoherent speech.
- Disorganised thought – difficulties in goal direction such that daily life is impaired.
- Catatonic behaviour – decrease in reactivity to environment (e.g., immobility, peculiar posturing, motiveless resistance to all instructions, absence of speech, flattened affect).
- Rapid or extreme mood swings or behaviour that is unpredictable or erratic (often in response to delusions or hallucinations; e.g., shouting in response to voices, whispering).
It is important to note that mood swings, agitation, and irritability without the presence of hallucinations or delusions does not mean that the person is not psychotic. Workers should respond to these clients in the usual way for such behaviour (described in this chapter), such as providing a calming environment so their needs can be met [541].
People in AOD settings commonly present with low-level psychotic symptoms, particularly as a result of cannabis or methamphetamine use. These clients may display a range of low-grade psychotic symptoms such as [541]:
- Increased agitation, severe sleep disturbance.
- Mood swings.
- A distorted sense of self, others, or the world.
- Suspiciousness, guardedness, fear, or paranoia.
- Odd or overvalued ideas.
- Illusions and/or fleeting, low-level hallucinations.
- Erratic behaviour.
Co-occurring AOD use adds to diagnostic uncertainty in presentations where there are symptoms of psychosis. For many people who experience psychotic symptoms as a direct effect of intoxication (auditory or visual hallucinations, paranoia) these experiences will resolve when the drug has left the body. These experiences may be considered by people who use AOD as a ‘bad trip’. If symptoms persist for periods beyond intoxication, however, it is important to consider whether they may be part of an emerging or underlying psychotic episode. This becomes likely where symptoms are persistent and distressing for at least one week (see Chapter B3). Although approximately one third of psychotic disorders are initially diagnosed as substance-induced [939], 25% are later revised to schizophrenia [38, 940]. Substance-induced psychosis may be virtually indistinguishable from an independent psychotic disorder at initial presentation [941], and longitudinal observation under abstinence conditions may be necessary to distinguish between them [102, 942]. The identification, management and treatment of substance-induced disorders are described in more detail later in this chapter. Irrespective of whether a person’s psychotic symptoms are substance-induced or not, early identification and intervention is key to optimal outcomes [943–945].