Journal of Dual Diagnosis
research and practice in substance abuse comorbidity
ISSN: 1550-4263 (Print) 1550-4271 (Online) Journal homepage: https://www.tandfonline.com/loi/wjdd20
Venkata Lakshmi Narasimha, Rahul Patley, Lekhansh Shukla, Vivek Benegal & Arun Kandasamy
To cite this article: Venkata Lakshmi Narasimha, Rahul Patley, Lekhansh Shukla, Vivek Benegal & Arun Kandasamy (2019): Phenomenology and Course of Alcoholic Hallucinosis, Journal of Dual Diagnosis, DOI: 10.1080/15504263.2019.1619008
To link to this article: https://doi.org/10.1080/15504263.2019.1619008
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JOURNAL OF DUAL DIAGNOSIS
Phenomenology and Course of Alcoholic Hallucinosis
Venkata Lakshmi Narasimha, MDa ￼ ￼, Rahul Patley, MBBSb, Lekhansh Shukla, DMb, Vivek Benegal, MDa, and Arun Kandasamy, MDa
aCentre for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India; bDepartment of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India
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Objective: The objective of the study was to examine the correlates, phenomenology, and short-term treatment response to benzodiazepines and antipsychotics in an inpatient sam- ple with alcohol-induced psychotic disorder, predominant hallucinations i.e., F10.52. Methods: We reviewed the charts of the patients admitted in a tertiary care addiction treat- ment center between 2010 and 2016 with the diagnosis of alcoholic hallucinosis. Results: Among 6,493 patients admitted with alcohol dependence during the study period, 61 patients (0.9%) had alcoholic hallucinosis. Among them, 41 (67.2%) had alcoholic hallucino- sis in the past; 26 (42.6%) had a family history of psychosis. Only auditory hallucinations were found in 46 patients (75.4%), only visual hallucinations in 3 patients (5%), and both auditory and visual hallucinations in 12 (19.7%). Thirty-four (55.7%) had delusions, which were secondary to hallucinations. Suicidality which includes suicidal ideas and attempts was noted in 12 (19.7%) patients. Fifty-three (86.9%) patients had hallucinations exclusively dur- ing alcohol withdrawal, while 8 (13.1%) had them during withdrawal as well as while con- suming alcohol. At the end of six months, 13.1% of the patients had an independent psychotic disorder diagnosed. The primary mode of management was treatment with only benzodiazepines (n1⁄437, 60.7%) or benzodiazepines and antipsychotics (n1⁄424, 39.3%). The reasons for starting antipsychotics were the presence of florid psychotic symptoms (26.2%) and incomplete symptom resolution with benzodiazepines (9.8%). The median duration of response was four days, with 25th to 75th quartile range at two to seven days. Conclusions: Alcoholic hallucinosis is an acute short-lasting psychotic disorder which lasts for less than a week when treated. Suicidality is high in this group, which needs attention. Benzodiazepines as part of withdrawal management may be sufficient for a majority of cases. Antipsychotics may be required in selected cases. A high degree of recurrence and morbidity indicates a need to intervene early with an abstinence-oriented manage- ment goal.
Received 13 January 2019 Revised 26 April 2019 Accepted 2 May 2019
Alcohol; hallucinosis; benzodiazepines; antipsy- chotics; suicide
Psychiatric diagnoses causally associated with alcohol use are currently conceptualized as alcohol use disor- ders and alcohol-induced disorders (American Psychiatric Association, 2013). For example, alcohol dependence syndrome (ADS) is characterized by loss of control, salience, craving, withdrawal syndrome, tolerance, and continued use despite harmful use which is equivalent to severe alcohol use disorder (American Psychiatric Association, 2013; World Health Organization, 1992). On the other hand, psychotic symptoms that start during or within 48hours of alcohol use, substantially resolve within a month, and completely resolve within six months
warrant a diagnosis of alcohol-induced psychotic dis- order (AIPD; F10.5; World Health Organization, 1992). Psychotic symptoms (i.e., hallucinations and delusions in the context of alcohol use) can occur during intoxication, withdrawal, and delirium tremens or as a manifestation of a reversible psychotic syn- drome attributable to excessive use. Per€al€a et al. have estimated the lifetime prevalence of “alcohol-induced psychotic syndrome” in the general population as 0.5% (Per€al€a et al., 2010). Under the broad diagnosis of AIPD, alcoholic hallucinosis is a distinct presenta- tion. It is characterized by acute onset, predominantly auditory hallucinations, intact sensorium, the absence of thought disorder and resolution within weeks
CONTACT Arun Kandasamy, MD in Psychiatry ￼email@example.com ￼Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences, Bengaluru 560029, India
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2 N. V. LAKSHMI ET AL.
(Glass, 1989; Jordaan & Emsley, 2014). The International Classification of Diseases includes alco- holic hallucinosis under the diagnostic code F10.25, alcohol-induced psychotic disorder, predominantly hallucinatory (World Health Organization, 1992).
While the presence of alcoholic hallucinosis has been accepted for more than a century (Bleuler, 1916), there are numerous uncertainties regarding its epidemiology, clinical course, and optimal treatment (Jordaan & Emsley, 2014). First, prevalence estimates as low as 0.4% to as high as 12% have been reported in various studies (see Jordaan & Emsley, 2014 for review). As a result, alcoholic hallucinosis is consid- ered either a rare condition or an underdiagnosed condition. Second, a recent review found a dearth of studies regarding treatment of AIPD (Masood, Lepping, Romanov, & Poole, 2018). This review con- cluded that currently available evidence for the man- agement of alcoholic hallucinosis is weak (level IV) due to paucity and heterogeneity of studies but favors antipsychotics as the first choice.
These uncertainties in epidemiology, clinical course, and treatment assume a higher import when the mor- bidity and mortality of AIPD are considered. For example, patients with AIPD have higher levels of anxiety, depression, and suicidality as compared to patients who have ADS without psychotic symptoms (Jordaan, Nel, Hewlett, & Emsley, 2009). Also, more than half of AIPD patients have a recurrence/rehospi- talization (Soyka, Helten, Cleves, & Schmidt, 2013), and some patients may go on to experience a dement- ing illness (Glass, 1989).
In this study, we set out to examine two questions of clinical relevance. First, what are the correlates and phenomenology of AIPD with predominant hallucina- tions (F10.52)? Second, what is the short-term response of this group of patients to two commonly used phar- macotherapies, benzodiazepines and antipsychotics?
This study was approved by National Institute of Mental Health and Neurosciences (NIMHANS) insti- tutional ethics committee board. We reviewed clinical data from the charts of the patients admitted with a diagnosis of AIPD (ICD-10- F10.5) between January 2010 and December 2016, at the Center for Addiction Medicine, at NIMHANS, Bangalore, India. This is a tertiary-level addiction treatment center attached to a teaching hospital meant for neuropsychiatric disorders which provides inpatient and outpatient services. As a standard procedure, each patient is seen by at least
two qualified psychiatrists before a diagnosis is made. In case of discrepancy, the case is reviewed by another psychiatrist and diagnosis is finalized based on con- sensus. We use a structured clinical assessment focus- ing on alcohol consumption (age at onset, quantity- frequency measures, duration of use, ICD-10 criteria for dependence), comorbidities (medical, psychiatric, and substance use–related) and family history (sub- stance-related and psychiatric disorders). A limited set of these variables are then entered in an elec- tronic database.
We manually reviewed all case files with a diagno- sis of AIPD and included cases which had hallucina- tions (with or without other psychotic symptoms). Each file was reviewed by two authors (VLN and RP). Mainly, disagreements arose about two decision points—the inclusion of the case (two cases) and treatment response (three cases). These files were then reviewed by another author (LS) to arrive at a deci- sion. Cases with a comorbid diagnosis which may explain psychotic symptoms like delirium, schizophre- nia, or mood disorder were excluded from the sample. Also, patients with active use of any substance (except nicotine) were excluded. It must be noted that a diag- nostic code is assigned to the patient only at the time of discharge; therefore, if patients experienced delir- ium during the course of the current treatment epi- sode, they were not included in this review. We have reviewed the post-discharge course up to six months or dropout from the treatment.
During this period, 6,493 patients were admitted for treatment of excessive alcohol consumption, all of them received a diagnosis of mental and behavioral disorders due to use of ADS (F10.2) and 153 cases received a diagnosis of AIPD additionally. However, 92 cases were excluded for the following reasons: erro- neous diagnostic code (n1⁄42), patients had only delu- sions and no hallucinations (n1⁄443), presence of a preexisting psychotic disorder (n 1⁄4 31), presence of delirium (n 1⁄4 6), cannabis use disorder (n 1⁄4 3), benzo- diazepine (BZD) use disorder (n 1⁄4 3), and inad- equately recorded psychopathology (n 1⁄4 4). Nearly 1% of all ADS patients (N 1⁄4 61) constitute the sample of this study. The sociodemographic and clinical charac- teristics are summarized in Table 1.
In this sample, 46 patients (75.4%) reported audi- tory hallucinations only, 3 patients (5%) reported vis- ual hallucinations only, and 12 (19.7%) patients had hallucinations in both visual and auditory modalities.
Table 1. Sociodemographic and clinical description of inpatients with diagnosed alcohol-induced psychotic disor- der–predominant hallucinations (N 1⁄4 61).
antipsychotics received either risperidone (2–6 mg/ day) or haloperidol (2.5–10mg/day), and only two patients received olanzapine. All the patients received thiamin (1500 mg/day for 5 days) along with multi- vitamin supplements. The median duration of response (defined as a substantial reduction or com- plete resolution of hallucinations) was 4days (inter- quartile range1⁄42–7days). At the end of sixmonths, eight (13.1%) of the patients’ diagnoses were revised and changed to an independent psychotic disorder. All these cases continued to involve hallucinations despite more than three months of abstinence. Of interest, these were the patients who had auditory hal- lucinations during intoxication as well as withdrawal and were already receiving an antipsychotic when they were discharged from the hospital.
In this study, we report the clinical characteristics, pharmacological treatment, and response of patients admitted with alcoholic hallucinosis in a tertiary care addiction treatment center. The prevalence of alco- holic hallucinosis in our center was found to be 0.9% of all alcohol-dependent patients who received inpatient treatment. We must consider the limitations of this study before discussing its generalizability and implications. First, it is a hospital-based study, since patients undergoing severe withdrawal are more likely to receive inpatient care, this study most likely overes- timates the prevalence of alcoholic hallucinosis. Second, there is a substantial risk of arbitrariness and bias due to the nature of this study. For example, the decision to prescribe antipsychotics along with BZD may be influenced by factors other than illness sever- ity. In turn, the mere fact that a patient is receiving antipsychotics may have biased the revision of diagno- sis to an independent psychotic disorder. Third, this sample consists only of male subjects, which may be because our center started an exclusive female addic- tion medicine ward in 2014. Keeping these limitations in mind, we wish to communicate four main findings of this study.
First, two-thirds of the patients had past episodes of alcoholic hallucinosis which highlights the recurrent nature of this illness. Although it is possible that this is an inflated estimate due to the nature of our sam- ple, this is in agreement with an earlier study from India showing a significant risk of recurrence (Perme, Vijaysagar, & Chandrasekharan, 2003). Therefore, it is prudent to expect hallucinations in a patient who has
JOURNAL OF DUAL DIAGNOSIS 3
Age in years (mean [SD]) Education (n [%])
Secondary Graduate or higher
Low socioeconomic status (n [%])a
Age in years at onset of F10.2 (mean [SD])b Family history of a psychotic illness (n [%])c History of F10.52 (n [%])b
Age at first episode of F10.52 (mean [SD])d
26 (42.6) 30 (49.2) 5 (8.2) 42 (68.9)
23.1 (6.7) 26 (42.6) 41 (67.2)
Note. SD 1⁄4 standard deviation.
aBelow poverty line patients who qualify for subsidized treatment. bAs per International Classification of Diseases (ICD 10).
cAbsent (n 1⁄4 20 [32.8%]) and unavailable (n 1⁄4 15 [24.6%]). dAvailable for 36 out of 61 patients.
Out of the 61 patients, 34 (55.7%) had delusions, which were all secondary to the hallucinations. Predominant types of delusions noted are persecutory (n1⁄420, 59%) and referential delusions (n1⁄47, 20.5%). Suicidality, which includes suicidal ideas as well as attempts, was noted in 12 (19.7%) patients, and all patients had significant anxiety symptoms as noted in the records. We did not find any first rank or negative symptoms in any of the records.
The review of the course of symptomatology sug- gests that the mean duration of hallucinosis before the presentation was 4days with 25th and 75th quartile range of 3 to 9.5days. A majority of patients (n1⁄453, 86.9%) reported that they experience hallucinations only when they decrease their alcohol intake or when they attempt to abstain completely. In these cases, hal- lucinations were also accompanied by symptoms of alcohol withdrawal like sweating, insomnia, anxiety, and tremulousness. In contrast, eight patients (13.1%) reported that they experience hallucinations when they consume their typical quantity of alcohol as well as when they attempt to decrease or stop alco- hol intake.
During the first week of inpatient stay, 37 (60.7%) patients were treated with only BZD, whereas 24 (39.3%) patients received an antipsychotic in addition to BZD. There were no cases in which an anti- psychotic was started in the absence of BZD. The rea- sons for using antipsychotics were either the presence of florid psychotic symptoms with a risk of harm to self or others (n1⁄416, 26.2%) or incomplete symptom resolution with BZD (n1⁄46, 9.8%). All of the patients received tapering doses of diazepam or lorazepam as BZD for the management of withdrawal symptoms and hallucinosis. The mean dose of BZD used on the first day was 66.16 mg (SD 1⁄4 29.73 mg) of diazepam equivalent. Most of the patients who received
4 N. V. LAKSHMI ET AL.
had them in the past and thus such cases may not be suitable for community detoxification.
Second, approximately one in five patients with alcoholic hallucinosis had suicidal ideation or attempts in the current episode. We believe that the high risk of suicide is related to the high affective arousal, intact psychomotor abilities, and the abrupt onset of alco- holic hallucinosis (Jordaan & Emsley, 2014). Reports from different parts of the world show violent self- injurious behavior during alcohol withdrawal (Patra, Sharma, Mehra, & Singh, 2014; Thomasson, Craig, & Guthrie, 2016), and alcoholic hallucinosis increases the risk of suicide over and above that associated with ADS (Jordaan et al., 2009). Thus, suicide risk assess- ment and management must be an integral part of acute treatment for patients with alcoholic hallucinosis.
Third, this study helps inform the choice of treat- ment for alcoholic hallucinosis. We must note that there are two schools of thought regarding alcoholic hallucinosis—one that purports it to be a schizophre- nia-like illness and another which views it to be akin of delirium tremens (Glass, 1989). As an extension, the choice of treatment is between agents that work on the gamma-amino-butyric-acid neurotransmission (e.g., BZD) or the dopaminergic system (e.g., antipsy- chotics). We observed that about 60% of patients had adequate symptom control with BZD itself. This is in contrast to a recent review that suggests antipsychotics as first-line treatment for AIPD (Masood et al., 2018). We believe that the most important reason for this is that our sample is dominated by “withdrawal hallucinosis.” We acknowledge that clinicians’ bias may have produced this finding. When you consider when a patient with ADS presents with new-onset hal- lucinations and mild alcohol withdrawal, one is inclined to start the treatment with BZDs as the first choice for two reasons. First, BZD will treat with- drawal syndrome and prevent seizures or delirium tre- mens. Second, if hallucinations respond well to BZD and do not recur, the clinician can be assured that the patient does not have a primary psychotic illness. Nevertheless, 40% of patients received an anti- psychotic agent in addition to BZD, indicating that both the treatments should be considered for alcoholic hallucinosis. Fourth, we found an average gap of 14 years between the onset of dependence and the first episode of alcoholic hallucinosis. This is in line with earlier studies showing an early onset of dependence (20–25 years of age) and the development of psychotic symptoms in the late third decade of life (Jordaan et al., 2009). Jordaan and Emsley suggest that this gap
between the onset of dependence and the appearance of psychosis distinguishes AIPD from a comorbid schizophrenic illness (Jordaan & Emsley, 2014).
In summary, this study reports that alcoholic hallucinosis is a short-lasting, possibly recurrent illness which carries a high risk of self-harm. The majority of patients respond promptly to BZD, but augmentation with antipsychotics may be warranted in some cases.
We would like acknowledge Center for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, India.
VLN, RP, LS, VB, and AK do not have any additional source of income to report and have not received any com- pensation for professional services from any other organiza- tion in the previous three years.
Venkata Lakshmi Narasimha
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