MJP Online Early 02-01-18 CASE REPORT Alcohol-Induced Psychotic Disorder with Suicidal Attempt: A Case Report Tengku Mohd Saifuddin, Chong Wei Wei, Aida Farina Ismail, Noorul Amilin Harun Department of Psychiatry, Hospital Tengku Ampuan Afzan, Pahang, Malaysia Abstract Alcohol-induced psychotic disorder (AIPD) is a rare complication of alcohol abuse which is characterized by an acute onset of auditory or visual hallucinations that occur either during or after a period of heavy alcohol consumption. Other symptoms include delusions, thought disorder, psychomotor disturbances, and abnormal affect. To establish the diagnosis, one must rule out other disorders such as alcohol withdrawal delirium or other psychotic disorders. Although it is well recognised, relatively little is known about the condition. Moreover, the pathogenesis and treatment of AIPD are still unclear despite high co-morbidity with other psychiatric disorders, high re-hospitalization as well as mortality rates and suicidal behaviour. Therefore, the prognosis appears less favourable. We present a case of young man with AIPD with suicidal attempt secondary to auditory hallucination. Keywords: Alcohol-induced Psychotic Disorder (AIPD) Introduction diagnosis of alcoholic hallucinosis [2]. Present evidence suggests AIPD can be Alcohol-induced psychotic disorder (AIPD) clinically distinguished from alcohol also known as alcoholic hallucinosis is a withdrawal delirium and schizophrenia. rare complication of chronic alcohol abuse Apart from that, AIPD is associated with [1]. It is characterized by an acute onset of high co-morbidity with other psychiatric auditory hallucinations that arise either disorders, high re-hospitalization and during or after a period of heavy alcohol mortality rates and suicidal behaviour intake. Other manifestations may include leading to a less favourable prognosis [3]. delusions, thought disorder, psychomotor Therefore, more exploration on this topic is disturbances, and abnormal affect. It is needed for further management of patients important to rule out other diagnoses such as with this condition. Here, we present a case alcohol withdrawal delirium or late onset of a young man with AIPD with suicidal psychotic disorder prior to establishing the attempt secondary to auditory hallucination. MJP Online Early 02-01-18 Case Report chest once. He thought the voices would disappear if he died. After stabbing himself, Mr MS, a 29 years old Malay man with a he ran out of the house and found his 16-year history of alcohol use and multiple mother. He was immediately brought to the physical co-morbidities, started hearing hospital for treatment. He sustained massive voices two to three days prior to the left haemothorax and was sent for admission. Those were multiple third- emergency exploratory thoracotomy. He person, male and female voices, which was then admitted to the cardiothoracic talked loudly near his ears. The voices were intensive care unit for one day before being discussing bad things about him. Also, the transferred to the cardiothoracic ward. voices would follow and comment on what he was doing, while he was showering. This This was the first incident of self-harm, and was not the first time he heard voices. He he was conscious at the time of the incident had 3-4 similar episodes of hearing voices in and was aware of his surroundings. His act the past three years (2015), but unlike the of stabbing himself with the knife was to kill previous episodes, this current episode was himself so that the voices would stop, and unusual as the voices were persistent, very this was unplanned. He denied he was being loud and clear as if the persons were talking controlled by other people or external next to his ears. He was unable to control the forces. He explained that if he did not voices. Before this, each episode lasted experience the disturbing voices, he would about two to three days. He was described as not attempt to harm himself. After he was well in between the episodes. saved, he felt remorseful but was unsure whether he would do this again if the voices Apart from that, he had a feeling that recurred. somebody was touching his arms and pressing his body. On the night before the After the incident and the surgery, he still incident, he saw a shadow of a human figure heard voices, but it was a voice calling his in front of his house, but he was unable to name from a far distance. It was transient tell who the person was or what the person and occurred mostly at night. The volume of was doing. He started to suspect somebody the voice was very soft, and the intensity was going to rob the house. He also believed had reduced significantly. He denied having that people wanted to cast black magic on visual or tactile hallucinations now. him. However, none of his family members However, he still believed that his shared the same beliefs. He was frightened symptoms were due to being black magic by and was unable to sleep for the night. people, though the belief was not as strong as before. On the next morning, the voices he heard became so loud that he was no longer able to He started taking alcohol when he was 13 tolerate. He did not confide in his mother years old. This was introduced by his regarding the disturbing voices but instead friends. Initially, he took alcohol 3 times per told his mother that he had abdominal pain week. However, after the accident in 2015, and requested mother to bring him to the his alcohol intake increased to daily use. For hospital. His mother then went to the the past 3 years, he took 2 bottles of 150ml neighbour’s house to seek help for liquor (local brands which contain 33% of transportation. Meanwhile, he took a knife alcohol) every day, spending RM15 per day from the kitchen and stabbed his left upper to buy the drinks. He drank as he did not MJP Online Early 02-01-18 have other activities to do. He usually took on and off. This was because he had alcohol alone or with his friends at the beach undergone multiple surgeries and near his house, in the evening, and he could complications including pain that had easily get alcoholic drinks in his village. affected his functions. There were also a Sometimes, he got drunk and fall asleep. He sense of emptiness and hopelessness, and had to continue taking alcohol as, if he did occasional passive death wishes but these not, he would turn irritable and would start were not persistent. His family noted him to having restlessness, hand and body be irritable and sometimes verbally abusive shakiness after 1 day. His longest period of especially when his demands were not abstinence was a week, in last year. He fulfilled. relapsed due to influence from his friend. His last use of alcohol (a bottle of Tyson) His sleep and appetite had been normal prior was the day before admission. to this incident. He denied symptoms of depression, anxiety and mania. He denied As he did not work, he had to ask his father having forgetfulness or other cognitive to give him money to buy alcohol. When the deterioration. father did not give him money, he would become angry, verbally and physically Mental state examination revealed a thin aggressive towards his family members. Malay man with good hygiene. He was calm There were many episodes when the father and cooperative. His speech was relevant was hit by him due to above reasons. and coherent. The mood was euthymic and the affect was appropriate and congruent to He claimed the good effect of alcohol was to his thoughts. He had no perceptual and make him happy. He knew the bad effects of thought disturbances. His cognition was alcohol especially on his pancreas. He was intact. The judgement and insight were also involved in a few accidents under the partial. The neurological examination was influence of alcohol, sustained injuries but unremarkable. denied history of having seizures. He wanted to cut down on his drinking and did In ward, he was started with benzodiazepine feel guilty but he continued to drink. He got and thiamine. No psychotropic medication annoyed when his parents told him to stop. was initiated in view of his psychotic He denied needing alcohol as eye-opener in symptoms improving. the morning. He denied taking other recreational drugs. He denied recent Discussion increased alcohol intake or getting drunk after taking the alcohol. He had no slurred Alcohol-induced psychotic disorder (AIPD) speech, loss of consciousness and unsteady is a relatively rare schizophrenia-like gait. After thoracotomy, he had mild craving disorder characterized by auditory for alcohol and hand tremors but no nausea hallucinations and delusions without or vomiting, anxiety, restlessness or disorders of consciousness and orientation. increased sweating. Like other psychotic disorders, it has a high risk for rehospitalization and relapse [4]. On further history, he admitted, for the past However, there was no history of admission three years, after he met with a motor to psychiatric ward in this patient. vehicle accident and sustained multiple injuries and was unable to work, he felt sad The lifetime prevalence of AIPD is 0.5% MJP Online Early 02-01-18 and highest among working age men (1.8%). Differentiating between alcoholic Younger age at onset of alcohol dependence, hallucinosis and schizophrenia is important low socioeconomic status, father’s mental because these conditions require different health or alcohol problems and multiple pharmacological treatment and further hospital treatments are associated with therapeutic management. Alcoholic increased risk of AIPD. Moreover, people hallucinosis is sometimes misdiagnosed as with earlier onset of alcohol problems with schizophrenia which leads to unnecessary associated drug use has higher relation with lifelong treatment with antipsychotics.