Primary Psychosis Research Articles

Electrocortical Responses to Emotional Stimuli in Psychotic Disorders: Comparing Schizophrenia Spectrum Disorders and Affective Psychosis.

Emotion dysfunction has long been considered a cardinal feature across psychotic disorders, including schizophrenia and affective psychosis. However, few studies have used objective markers of emotional function to compare psychotic disorders to one another, and fewer studies have examined such markers within a longitudinal framework. Here, we examine one objective marker of emotional responsivity, the late positive potential (LPP), which is a centro-parietal event-related potential (ERP) that tracks the dynamic allocation of attention to emotional vs. neutral stimuli. We used the LPP to characterize abnormal emotional responsivity by relating it to negative, depressive, and psychotic symptoms among two clinical groups: individuals diagnosed with affective psychosis and individuals with schizophrenia. We also used a long-term longitudinal framework, examining concurrent associations between LPP amplitude and symptom severity, as well as prospective associations with symptoms 4 years later. Participants were 74 individuals with psychotic illness: 37 with schizophrenia spectrum disorders and 37 with a primary affective disorder (psychotic bipolar disorder, psychotic depression). There were no mean-level differences in LPP amplitude between the schizophrenia spectrum and primary affective psychosis group. In the primary affective psychosis group, reduced LPP amplitude was associated with greater depressive, negative, and psychotic symptom severity, both concurrently and at follow-up; associations between LPP and symptoms were not observed within the schizophrenia spectrum group. This pattern of results suggests that the neural correlates of emotion dysfunction may differ across psychotic disorders. One possibility is that schizophrenia is characterized by a decoupling of symptom severity and emotional processing. Such findings underscore the importance of analyzing transdiagnostic samples to determine common or specific symptom relationships across various patient populations.

Impact of comprehensive treatment for first episode psychosis on substance use outcomes: A randomized controlled trial

Lifetime co-occurring substance use disorders are common at the time of presentation for treatment of a first episode of primary psychosis and persistent substance use disorder (SUD) leads to poorer outcomes. We assessed whether the NAVIGATE program, a coordinated specialty care service that includes optional substance abuse content reduced substance use compared to usual care in 404 individuals in the Recovery After Initial Schizophrenia Episode-Early Treatment Program (RAISE-ETP) study. Participants were randomized to two years of NAVIGATE (n = 223) or usual care (n = 181) and assessed monthly for substance use. At baseline, over one-half (51.7%) of the participants met criteria for a lifetime SUD, including over one-third with alcohol use disorder (36.4%) and with cannabis use disorder (34.7%). Contrary to our hypothesis, there was no treatment group by time interaction effect on days of self-reported substance use over the two-year follow-up. Participant exposure to the substance abuse component of the NAVIGATE program was low, suggesting that modifications to the program and training method for clinicians may be needed. Further research is needed to determine the most effective strategies for addressing substance use disorders in persons recovering from a first episode of psychosis.

Organic psychosis: The pathobiology and treatment of delusions.

Organic or secondary psychosis can be seen in diverse conditions such as toxic/metabolic disorders, neurodegenerative disease, and stroke. Poststroke psychosis is a rare phenomenon, but its study has significantly contributed to the understanding of delusion formation. The evidence from case studies of patients with focal strokes shows that delusions develop following unilateral damage of the right hemisphere. The majority of patients with right hemisphere stroke do not develop delusions however, and advanced neuroimaging analysis has elucidated why this symptom develops in only a small proportion. Lesions of the right lateral prefrontal cortex or lesions with connectivity to this area correlate with delusional beliefs in this subgroup. Studies of patients with primary psychosis, for example schizophrenia, or under the influence of the psychotogenic drug ketamine, also show abnormal function of this area in relation to the severity of their abnormal beliefs. The conclusion of these studies is that the right lateral prefrontal cortex is 1 hub in a neural network which includes the basal ganglia and limbic system and receives inputs from midbrain dopamine neurones. In patients with schizophrenia, or at risk of psychosis, dopamine is dysregulated and evidence suggests that faulty dopamine signaling is the precursor of delusion formation. It is therefore likely that the mechanism of delusion formation is the same in both primary and secondary psychosis. This is consistent with the mainstay of treatment of both conditions being antipsychotic medication. However, antipsychotic medication in people with cerebrovascular disease should be avoided if at all possible. This is because epidemiological studies have found that antipsychotic use is associated with an increased risk of stroke and will thus compound the possibility of a further cerebrovascular accident.

Substance-Induced Psychosis: An Indicator of Development of Primary Psychosis?

Substance-Induced Psychosis: An Indicator of Development of Primary Psychosis?

T254. IMPACT OF A DROP IN, OPEN ENDED, PSYCHO EDUCATIONAL GROUP ON CLIENT ENGAGEMENT IN AN EARLY PSYCHOSIS INTERVENTION PROGRAM

BackgroundParticipating in groups are a critical part of rehabilitation model in Early Psychosis Intervention. Effectiveness of intervention is dependent on the willingness of an individual to engage and remain engaged throughout the duration of the intervention. Approximately 30% of individuals with a first episode of psychosis disengage from services despite ongoing needs.On Track is a community based mental health outpatient program specialized in early assessment & treatment of psychosis. Client population includes individuals aged 16 to 35 years residing in the North East of Ontario, Canada.The program offers psychiatric follow up as well as unique group based interventions. Clients are required to be screened for group suitability & community safety prior to participation. Program evaluation highlighted challenges to engage clients. An open-ended, psycho-educational, drop in group called “The Café” was developed.MethodsStudy used a mixed‐methods approach to evaluate the impact of the Café sessions on clients & their engagement in the program. Data was collected between December 2016 to June 2017. All clients were diagnosed with primary psychosis disorder. Patient experiences & engagement level were measured using a questionnaire & the Singh-O’Brien Level of Engagement Scale.Results43 clients participated in 29 Café sessions in seven months. Average number of participants per session was 7.3 (SD=3.05). Over 72% of clients participated in at least one to five sessions. Average age was 23.9 (SD=0.6). Participants were predominantly male (82%), white (42%), English speaking (93%), living with their parents (76.2%), no employment (69%), with some college or university degree (45.2%). Primary source of income were their families (47.6%). Over 59% of participants were in the program one year or less, 18.2 % & 22.7 % of participants have been in the program for two & three years, respectively.The engagement score among males did not differ significantly from females (t(42)=-0.94, p=0.35). There was no significant differences in engagement scores between ethnic groups (F(4)=2.84, p=0.062). There was a marginally significant difference in engagement score between program duration groups (F(2)=3.23, p=0.051); the engagement score for clients who have been enrolled in the program for over two years were slightly higher than one year clients.41% of clients attended Café before participating in any other groups; 4 of them joined other recreational & leisure groups. 3 clients later enrolled in a skill based group. 92% of respondents commented about the benefit of Café to their recovery as being “good” or “better”. Qualitative data identified socializing, coping with illness, & drop in nature of the Café as main themes contributing to recovery.DiscussionIn an attempt to increase opportunities for engagement, our program developed a drop in Café style group to provide client centered psycho-education group. The result of our intervention showed that the Café provided benefits to client’s engagement and recovery. The Café facilitated additional engagement in both recreational and leisure & skill based group streams. The drop in nature of the Café was advantageous to increasing engagement. Participation in the Café resulted in improvements in coping with the illness & socialization. Clients who had been enrolled in our program for 2 years reported higher levels of engagement compared to clients newly enrolled.Evaluating our intervention through collecting both qualitative & quantitative data provided us with a better understanding of the impact of the open- ended, drop in nature, psycho-education based group. Involvement of both client’s and families in the identification of the topics was another advantage of our study.

A clinical approach to new-onset psychosis associated with immune dysregulation: the concept of autoimmune psychosis

Growing data point to the overlap between psychosis and pathological processes associated with immunological dysregulation as well as inflammation. Notably, the recent discovery of antibodies against synaptic and neuronal cell membrane proteins such as anti-N-methyl-d-aspartate receptor provides more direct evidence of the etiological connection between autoimmunity and subsequent hazard of psychosis. Here, we advocate the use of term “autoimmune psychosis,” as this term suggests that autoimmune disorders can masquerade as drug-resistant primary psychosis, and this subtype of psychosis has anatomical and immunological footprints in the brain, despite the frequent absence of structural abnormalities on conventional brain MRI. Furthermore, this term might serve as a reminder not to overlook appropriate neurological workup such as neuroimaging and EEG testing, as well as CSF analysis, for cases with acute or subacute atypical onset of neuropsychiatric presentations including those dominated by acute psychotic symptoms. We propose etiologically and serologically oriented subclassification as well as multi-modal diagnostic approach to address some of the challenges inherent to early diagnosis of patients presenting with atypical and refractory new-onset psychotic symptoms of autoimmune origin. This is particularly relevant to the diagnosis of seronegative but probable autoimmune psychosis (SPAP) that might masquerade as antipsychotic drug-resistant primary psychotic disorder. This distinction is therapeutically important as autoimmune-related psychotic symptomatology can frequently respond well to timely treatment with proper immune modulatory therapies.

Alcohol Habits and Health Care Use in Patients with Psychiatric Disorders

ABSTRACTObjective: It is common for persons with psychiatric disorders to also have alcohol problems. Studies in the general population as well as in clinical samples have found hazardous or harmful alcohol habits to be particularly prevalent in the presence of psychiatric disorders. This study sought to explore the relationships between drinking habits and health care utilization (psychiatric as well as general medical) in persons seeking psychiatric treatment and to investigate the associations among age, sex, and type or number of diagnoses and health care use and costs. For the planning of targeted interventions, we also sought to identify subgroups with a high prevalence of hazardous drinking habits. Methods: From a psychiatric clinic for affective disorders at a university hospital in Sweden, patients who had been screened for hazardous drinking (N = 609) were selected. Patients with primary psychosis or substance use disorder receive treatment at other clinics and did not participate. Medical records data were grouped and compared. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) was used for diagnoses and the Alcohol Use Disorders Identification Test for screening. Patients were grouped by drinking habits and sex, age, and diagnosis group, and their psychiatric as well as general medical health care use was compared. Results: Abstainers used psychiatric care more than all other drinking groups (p < .001). Psychiatric health care costs were higher in abstainers and low-risk drinkers (1.64 to 1). No differences in general medical care could be identified between drinking groups. Specific subgroups with higher rates of hazardous drinking could not be identified (44% of all males and 34% of all females reported such habits). Inconclusive results from previous research are most likely due to different methods used to classify drinking problems. Conclusions: Abstainers and low-risk drinkers used psychiatric health care to a higher cost than the other drinking groups. Possible explanations are discussed from a clinical and scientific perspective. This study clarifies the need for uniform measures when classifying alcohol use in studies of relationships between alcohol use and health care use. There is also a need to separate former drinkers from abstainers in future studies.

Primary psychosis with comorbid drug abuse and drug-induced psychosis: Diagnostic and clinical evolution at follow up.

The study reports a follow-up assessment of 48 patients with concomitant drug abuse at the first admission for psychosis. We focused on the diagnostic distinction between primary psychosis with concomitant drug abuse and drug induced psychosis, to observe whether the diagnoses are stable over time and whether the clinical course significantly differs. The study examined 25 primary psychotic disorder with comorbid drug abuse and 23 drug-induced psychotic disorder patients. Diagnostic and psychopathological assessments were made at baseline and at follow-up. Mean follow-up period was 4.96 years. Patients with comorbid Drug Abuse exhibited higher scores in the item Unusual Content of Thought at baseline than drug-induced psychotic disorder patients: 5.48 vs 4.39 while the two patients groups did not differ in any of the BPRS items evaluated at follow-up. The primary psychosis with comorbid drug abuse and the substance induced psychosis groups were similar regarding diagnostic stability, and a diagnosis of schizophrenia at follow-up occurred similarly. There was no evidence that Drug Induced psychotic patients' symptoms tend to improve more after cessation of drug abuse. An earlier age of onset was found in primary psychotic patients, particularly for patients diagnosed as affected by schizophrenia at follow up. These results might reflect the uncertainty of the distinction between Primary and Drug Induced Psychosis and the difficulties in applying the DSM IV-TR criteria for diagnosing comorbid drug use disorders and psychotic disorders.

Differences in the symptom profile of methamphetamine-related psychosis and primary psychotic disorders

We examined the lifetime experience of hallucinations and delusions associated with transient methamphetamine-related psychosis (MAP), persistent MAP and primary psychosis among a cohort of dependent methamphetamine users. Participants were classified as having (a) no current psychotic symptoms, (n=110); (b) psychotic symptoms only when using methamphetamine (transient MAP, n=85); (c) psychotic symptoms both when using methamphetamine and when abstaining from methamphetamine (persistent MAP, n=37), or (d) meeting DSM-IV criteria for lifetime schizophrenia or mania (primary psychosis, n=52). Current psychotic symptoms were classified as a score of 4 or more on any of the Brief Psychiatric Rating Scale items of suspiciousness, hallucinations or unusual thought content in the past month. Lifetime psychotic diagnoses and symptoms were assessed using the Composite International Diagnostic Interview. Transient MAP was associated with persecutory delusions and tactile hallucinations (compared to the no symptom group). Persistent MAP was additionally associated with delusions of reference, thought interference and complex auditory, visual, olfactory and tactile hallucinations, while primary psychosis was also associated with delusions of thought projection, erotomania and passivity. The presence of non-persecutory delusions and hallucinations across various modalities is a marker for persistent MAP or primary psychosis in people who use methamphetamine.

Camminando filo di una diagnosi differenziale. Il caso di Mario

This work proposes some reflections about the theme of differential diagnosis between primary psychosis and chemically-induced psychosis, mainly at early stages of the disease. Hence, the description of the case history of a patient who, after first compulsory admission and involuntary treatment, was diagnosed with “substance-induced psychotic disorder”. Some of the patient’s clinical features, such as affective flatness and his not really asking for help, together with finding out about a mental health condition at risk which dated back to two years prior to psychotic onset, supported the hypothesis that the patient was affected by primary psychosis rather than a psychosis due to psychotropic substances. In order to distinguish between substance-induced psychosis and primary psychosis, it is therefore fundamental to couple categorical diagnosis with a psychodynamic-type diagnosis which not only takes into account symptoms and behaviour.

Primary psychosis and Borna disease virus infection in Lithuania: a case control study.

BackgroundThe hypothesis that microbial infections may be linked to mental disorders has long been addressed for Borna disease virus (BDV), but clinical and epidemiological evidence remained inconsistent due to non-conformities in detection methods. BDV circulating immune complexes (CIC) were shown to exceed the prevalence of serum antibodies alone and to comparably screen for infection in Europe (DE, CZ, IT), the Middle East (IR) and Asia (CN), still seeking general acceptance.MethodsWe used CIC and antigen (Ag) tests to investigate BDV infection in Lithuania through a case-control study design comparing in-patients suffering of primary psychosis with blood donors. One hundred and six acutely psychotic in-patients with no physical illness, consecutively admitted to the regional mental hospital, and 98 blood donors from the Blood Donation Centre, Lithuania, were enrolled in the study. The severity of psychosis was assessed twice, prior and after acute antipsychotic therapy, by the Brief Psychiatric Rating Scale (BPRS). BDV-CIC and Ag markers were tested once after therapy was terminated.ResultsWhat we found was a significantly higher prevalence of CIC, indicating a chronic BDV infection, in patients with treated primary psychosis than in blood donor controls (39.6 % vs. 22.4 %, respectively). Free BDV Ag, indicating currently active infection, did not show significant differences among study groups. Higher severity of psychosis prior to treatment was inversely correlated to the presence of BDV Ag (42.6 vs. 34.1 BPRS, respectively; p = 0.022).ConclusionsThe study concluded significantly higher BDV infection rates in psychotic than in healthy Lithuanians, thus supporting similar global trends for other mental disorders. The study raised awareness to consider the integration of BDV infection surveillance in psychiatry research in the future.

Medical mimics: Differential diagnostic considerations for psychiatric symptoms.

Patients with underlying medical disease can present to the health care system with psychiatric symptoms predominating. Identification of an underlying medical condition masquerading as a psychiatric disorder can be challenging for clinicians, especially in patients with an existing psychiatric condition. The term medical mimic or secondary psychosis has been used to describe this clinical situation. Diagnostic categories from The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, that may encompass medical mimics include substance-induced disorders, which includes medications, and unspecified mental disorder due to another medical condition in situations where the clinician may lack needed information for a complete diagnosis. At this time, there is no single diagnostic test or procedure available to differentiate primary versus secondary psychosis on the basis of psychopathology presentation alone. When considering a diagnosis, clinicians should evaluate for the presence of atypical features uncharacteristic of the psychiatric symptoms observed; this may include changes in functionality and/or age of onset and symptom presentation severity. The purpose of this work is to provide a structured clinical framework for evaluation for medical mimics, identify groups considered to be at highest risk for medical mimics, and present common syndromic features suggestive of a medical mimic. Selected case scenarios are used to illustrate key concepts for evaluating and assessing a patient presenting with acute psychiatric symptomatology to improve judgment in ruling out potential medical causality.

P.3.b.039 - First-episode primary psychosis with comorbid drug abuse and drug-induced psychosis: diagnostic stability and clinical evolution at long-term follow up

To assess the mechanism by which a collaborative care (CC) intervention improves self-reported abstinence among primary care patients with opioid and alcohol use disorders (OAUD) compared to treatment as usual.Secondary data analysis of SUMMIT, a randomized controlled trial of CC for OAUD. Participants were 258 patients with OAUD receiving primary care at a multi-site Federally Qualified Health Center. Using a mediation analysis decomposition of a total effect into a mediated and a direct effect, we examined the effect of CC on abstinence at six months, attributable to the HEDIS treatment initiation and engagement measures for the total sample, for individuals with alcohol use disorders alone, and for those with a co-morbid opioid use disorder.Although the CC intervention led to an increase in both initiation and engagement, among the full sample, only initiation mediated the effect of the intervention on abstinence (3.8%, CI=[0.4%, 8.3%]; 32% proportion of the total effect). In subgroup analyses, among individuals with comorbid alcohol and opioid use disorders, almost 100% of the total effect was mediated by engagement, but the effect was not significant. This was not observed among the alcohol use disorder only group.Among primary care patients with OAUDs, treatment initiation partially mediated the effect of CC on abstinence at 6-months. The current study emphasizes the importance of primary care patients returning for a second substance-use related visit after identification. CC may work differently for people with co-morbid opioid use disorders vs. alcohol use disorders alone.

Psychosis induced by amphetamines.

The study reviews publications on the use of methamphetamine and amphetamine in relation to psychotic symptoms, substance-induced psychosis, and primary psychosis published between July 2014 and December 2015. The databases MEDLINE, Embase, and PsycINFO were searched using the terms 'amphetamine psychosis' and 'methamphetamine psychosis' for the time period 1 July 2014 to 31 December 2015. There were 37 studies published on the subject during this time period. Risk factors for psychotic symptoms, substance-induced psychosis, and primary psychosis included patterns of drug use, but results also pointed to the importance of nondrug-related vulnerability. Cognitive impairment is associated with both amphetamine use and psychosis, and the impairment among those with amphetamine-induced psychosis resembles that of schizophrenia. At the neuronal level, GABAergic mechanisms may offer some understanding about the association between stimulant use and psychosis. Several different types of antipsychotic medication are effective for treating agitation and psychosis, but drugs with high DRD2 blockade should be used with caution. Some novel treatments are described, but are not sufficiently repeated to be recommended. During the past 18 months, studies have been published that cover risk factors, neuronal mechanisms, and treatment. These recent results do not differ from previous understandings, but the role of cognition and GABAergic dysfunction should be further investigated, and knowledge about resilience factors is still scarce. Also, a clearer evidence base for medical treatment of psychosis with concurrent amphetamine use is warranted. VIDEO ABSTRACT.

Symptom Profile of Substance-induced Psychosis Versus Primary Psychosis in a Sample of Egyptian Patients: A Preliminary Study

Introduction: There is an extensive literature on the link between psychosis and substance use. The nature of this association has been a matter of controversy for the last 2 decades, especially the possible cause effect relationship that may be involved in this association. The differential diagnosis of substance-induced psychotic disorder and primary psychotic disorder is particularly challenging during an acute admission when psychotic symptoms are the most severe and the identification of possible markers of these disorders could simplify their recognition and treatment. Objectives: The main objective of the current study was to compare the clinical picture between a sample of patients with substance-induced psychosis (SIP) and patients with primary psychosis, as regards the phenomenological aspects and to study the different correlates affecting their clinical picture. Materials and Methods: A comparative cross-sectional study including 22 patients with first-episode psychotic disorder recruited from the inpatient wards of the Institute of Psychiatry Ain-Shams University. All patients were interviewed between 1 week and 1 month of onset of symptoms using Structured Clinical Interview for DSM-IV (SCID-I) and Positive and Negative Syndrome Scale (PANSS). Patients were labeled into 2 groups according to diagnosis, group I: patients fulfilling criteria of brief psychotic episode. Group II: patients fulfilling criteria of substance-induced psychotic disorder. Results: No statistical difference between the 2 studied groups as regard PANSS score positive, negative, and general psychopathology, as well as the severity of symptoms. However, further analysis of the PANSS score components showed SIP group to have significantly higher P4 (excitement) score (P=0.02), G10 (disorientation) score (P=0.03), and G11 (poor attention) score (P=0.004). Conclusions: This study adds to a growing body of literature highlighting the differences between SIP and primary psychosis. It provides set of variables that distinguish the substance-induced and primary psychosis groups from one another, which should be an area for further studies.

Differences in Clinical Features of Methamphetamine Users with Persistent Psychosis and Patients with Schizophrenia

Background: Methamphetamine exerts neurotoxic effects and elicits psychotic symptoms. This study attempted to compare clinical differences between methamphetamine users with persistent psychosis (MAP) and patients with schizophrenia. In addition, we examined the discrimination validity by using symptom clusters to differentiate between MAP and schizophrenia. Methods: We enrolled 53 MAP patients and 53 patients with schizophrenia. The psychopathology of participants was assessed using the Chinese version of the Diagnostic Interview for Genetic Studies and the 18-item Brief Psychiatric Rating Scale. Logistic regression was used to examine the predicted probability scores of different symptom combinations on discriminating between MAP and schizophrenia. The receiver operating characteristic (ROC) analyses and area under the curve (AUC) were further applied to examine the discrimination validity of the predicted probability scores on differentiating between MAP and schizophrenia. Results: We found that MAP and schizophrenia demonstrated similar patterns of delusions. Compared to patients with schizophrenia, MAP experienced significantly higher proportions of visual hallucinations and of somatic or tactile hallucinations. However, MAP exhibited significantly lower severity in conceptual disorganization, mannerism/posturing, blunted affect, emotional withdrawal, and motor retardation compared to patients with schizophrenia. The ROC analysis showed that a predicted probability score combining the aforementioned 7 items of symptoms could significantly differentiate between MAP and schizophrenia (AUC = 0.77). Conclusion: Findings in the current study suggest that nuanced differences might exist in the clinical presentation of secondary psychosis (MAP) and primary psychosis (schizophrenia). Combining the symptoms as a whole may help with differential diagnosis for MAP and schizophrenia.

Psychopathological effects of psychostimulant substances and psychotic onset: the difficult process of differential diagnosis between substance-induced psychosis and acute primary psychosis

Amongst the psychopathological effects induced by stimulants and cocaine there can be a variety of psychotic-like experiences. Some of them can be resolved in a matter of hours or a few days without clinical tratment, others instead can constitute initial symptoms of a primary psychosis. The objective of this paper is to focalise on a series of psychodynamic aspects, detectable by the analysis of relational dynamics brought into play by the person who has used the substances and has a psychotic crisis. These aspects can be used as criteria of a differential diagnosis, to integrate a first assessment of those psychopathological characteristics described in literature, which distinguish a toxic psychosis from a primary psychosis. The diagnostic process is developed by a method of clinical observation and evaluation, for which the essential cognitive tool is formed by the sensibility of the therapist and their capacity to evaluate the quality of the patient's mental reactions to the stimulus provoked by the development of the therapeutic relationship, which includes oneiric activity. This paper proposes, on the basis of many years of research and clinical experience, diagnostic criteria also in dream analisysis as oneiric images are able to reveal hidden thoughts and dynamics which can be pathological, like negations or annullaments, or non pathological intuitions. This analysis can detecte eventual psychopathological nucleus of psychosis hidden by a state of intoxication and consent the implementation of adequate clinical treatment based on greater diagnostic certainty.

Understanding the Relationship Between Amphetamines and Psychosis

Use of amphetamine and methamphetamine (hereafter amphetamines) can cause acute psychotic symptoms and may also contribute to persistent psychotic conditions such as schizophrenia. Still, much remains uncertain about the mechanisms and nature of this relationship. In this paper, we review certain aspects of this relationship, with particular emphasis on papers published during the past 3 years. A review of the literature reveals that, in addition to the established knowledge that amphetamines can cause acute psychotic symptoms, more evidence has emerged that amphetamines may play a role also in the pathogenesis of schizophrenia. Determining causality for the amphetamine-psychosis association has, however, proven complicated. Reversed causality may be the case, as may be the notion that both use of amphetamines and psychosis reciprocally affect each other with deteriorating effects on both conditions. Clinical features like sensitization to amphetamines precipitating psychosis, that even amphetamine-induced psychosis may persist, and diagnostic transition from amphetamine-induced to primary psychosis suggest a continuous and mutual interaction between individual vulnerability, amphetamine exposure, and psychosis. The high transition rates also point to amphetamine-induced psychosis as a major risk factor for primary psychosis. Mortality rates are high for both psychosis and use of amphetamines, and we lack high-quality treatment guidelines to apply when these two conditions occur together. Amphetamine-induced psychosis may be more affiliated with primary psychosis than previously assumed. Some clinical implications are suggested.

Long-term risk factors for substance-induced and primary psychosis after release from prison. A longitudinal study of substance users

PurposeThe purpose of this study was to determine long-term risk factors for substance-induced and primary psychosis after release from prison. MaterialWe used a longitudinal register-based cohort study combining European version of Addiction Severity Index (Europ-ASI) interviews and the Swedish inpatient register. The study included 6217 individuals who were in the Swedish criminal justice system from 2001 to 2006. MeasurementsThe outcomes were substance-induced and primary psychosis as defined by the International Classification of Disease — 10th version. All variables for estimating baseline risk were drawn from the Europ-ASI interview, and included information on substance use, demographics and health. The interview database and the inpatient register were coupled, and groups were compared by using tests of significance and logistic regression. ResultsPolydrug use was the strongest predictor for substance induced psychosis (OR=9.55, 95% CI 3.42–26.67), but all substances imposed an increased risk. Previous psychiatric hospitalization and non-drug related hallucinations were significant, but weaker, risk factors. The only substance variable that predicted primary psychosis was cannabis (OR=2.62, 95% CI 1.39–4.96), but previous psychiatric hospitalization (OR=3.22, 95% CI 2.27–4.54) and non-drug related hallucinations (OR=4.00, 95% CI 2.82–5.67) were even stronger predictors. ConclusionsCannabis use was a risk factor for primary psychosis, but other health related individual risk factors were even more important. Polydrug use was the strongest risk factor for substance-induced psychosis.

Psychopathological Effects of Psychostimulant Substances and Psychotic Onset: the Difficult Process of Differential Diagnosis Between Substance-induced Psychosis and Acute Primary Psychosis

Amongst the psychopathological effects induced by stimulants and cocaine there can be a variety of psychotic-like experiences. Some of them can be resolved in a matter of hours or a few days without clinical tratment, others instead can constitute initial symptoms of a primary psychosis. The objective of this paper is to focalise on a series of psychodynamic aspects, detectable by the analysis of relational dynamics brought into play by the person who has used the substances and has a psychotic crisis. These aspects can be used as criteria of a differential diagnosis, to integrate a first assessment of those psychopathological characteristics described in literature, which distinguish a toxic psychosis from a primary psychosis. The diagnostic process is developed by a method of clinical observation and evaluation, for which the essential cognitive tool is formed by the sensibility of the therapist and their capacity to evaluate the quality of the patient's mental reactions to the stimulus provoked by the development of the therapeutic relationship, which includes oneiric activity. This paper proposes, on the basis of many years of research and clinical experience, diagnostic criteria also in dream analisysis as oneiric images are able to reveal hidden thoughts and dynamics which can be pathological, like negations or annullaments, or non pathological intuitions. This analysis can detecte eventual psychopathological nucleus of psychosis hidden by a state of intoxication and consent the implementation of adequate clinical treatment based on greater diagnostic certainty.