Author:
Timothy M.Scarella
Description
Disorder of brain function characterized illogical, bizarre, or delusional beliefs, abnormal perceptions, and disorganization of emotions, thought, and behavior
Etiology
Psychiatric
- Primary psychotic disorders:
- Schizophrenia: >6 mo 2 of the following: Hallucinations, delusions, negative symptoms, disorganized thought, disorganized behavior
- Brief psychotic disorder if symptoms <1 mo, schizophreniform disorder if symptoms 1-6 mo
- Schizoaffective disorder: Prominent mood symptoms concurrent with psychotic decompensations
- Delusional disorder: Presence of rigid delusion without other symptoms of psychosis
- Mood disorders:
- Mania with psychotic features
- Depression with psychotic features
- Psychiatric mimics of psychosis (not true psychotic disorders but may resemble them):
- Posttraumatic stress disorder: May involve strong referential thinking and fear of being in danger out of proportion with objective reality
- Borderline personality disorder: May involve strong referential thinking and related affective lability
- Obsessive-compulsive disorder: Nature of obsessions may be so illogical and rigid as to seem psychotic
- Neurodevelopmental disorders: Those with autism or intellectual disability may have odd/bizarre/unrealistic beliefs or experience internal thoughts as “voices”
Medical, Nonpsychiatric
- Neurologic disease:
- Delirium (prominent confusion, inattentiveness, waxing/waning level of consciousness; may include perceptual disturbances and illogical/delusional thinking)
- Head injury
- Dementia (hallucinations and delusions may occur in any dementia including Alzheimer, Lewy body, frontotemporal)
- Cerebrovascular accident (acute or chronic)
- Seizures (inter-/postictal)
- Space-occupying lesions (neoplasm, abscesses, cysts)
- Hydrocephalus
- Demyelinating diseases (multiple sclerosis)
- Neuropsychiatric disorders (Parkinson disease, Huntington disease, Wilson disease)
- Prion disease
- Infectious disease:
- Meningitis/encephalitis (bacterial, viral, or fungal)
- HIV
- Tertiary syphilis
- Tertiary Lyme disease
- Metabolic:
- Intoxication (psychostimulants, hallucinogens, ketamine, phencyclidine, cannabinoids, MDMA, dextromethorphan)
- Adverse medication effect (cyclosporine, cycloserine, corticosteroids, fluoroquinolones, amantadine, levodopa, pramipexole, levetiracetam)
- Hypercalcemia
- B12 deficiency
- Heavy metal poisoning (arsenic, mercury)
- Porphyria
- Endocrine:
- Thyroid disease
- Cushing syndrome
- Adrenal insufficiency
- Autoimmune disease:
- Lupus cerebritis (usually accompanies neurologic symptoms such as seizure)
- Autoimmune encephalitis (i.e., anti-NMDA)
- Paraneoplastic syndrome
- Toxins:
- Heavy metals
- Organophosphates
- Carbon monoxide
Signs and Symptoms
- Delusions are fixed, false beliefs that:
- Are impervious to outside logic
- Often involve persecutory, religious, or somatic content
- Hallucinations:
- Sensory experiences in the absence of external stimuli
- Can involve any sensory modality; auditory and visual are most common
- Contrast with illusions, which involve altered sensory processing of a true stimulus (i.e., coat rack thought to be a person), common in delirium but also occur in psychotic disorders
- Disorganized thought:
- Idiosyncratic logic, loosening of associations, tangential or circumferential speech
- Language abnormalities: Neologisms, clang associations, word salad
- Disorganized behavior:
- Unpredictable or inappropriate behavior
- Impulsiveness
- Strange or purposeless behavior
- Inability to perform ordinary tasks
- Negative symptoms:
- Flattened affect
- Apathy
- Anhedonia
- Social isolation
- Poverty of thought content
- Catatonia:
- More common in medical conditions and mood disorders
- Can occur in psychosis
- Motor manifestations: Rigidity, akinesia OR hyperkinesia, posturing, waxy flexibility, odd/purposeless movements
- Echopraxia (mimics examiners movements)
- Echolalia (repeats what examiner says)
- Automatic obedience, negativism (resistance of instructions), grasp reflex
- Vital sign abnormalities
- Features suggesting a nonpsychiatric etiology:
- Sudden onset
- New onset >30 yr old
- Fluctuating course
- Focal neurologic symptoms
- Abnormal vital signs
- Visual, olfactory, gustatory, or tactile hallucinations
- Impairment of orientation, attention, or cognitive function
History
- Screen for all psychosis symptoms, including onset, duration, triggers, and content
- Delusions:
- “Are you in danger? Do you feel anyone is trying to hurt you, or that anyone is monitoring you?”
- “Is anyone trying to send you messages, read your thoughts, or block your thinking?”
- “Do you have any special abilities?”
- Hallucinations:
- “Do you ever see or hear things that other people cannot see or hear?”
- “Do you ever hear voices telling you to do things such as to harm yourself or to harm others?”
- Suicidal or homicidal behavior or threats
- Past medical and psychiatric history
- Social situation and ability to care for self
- Recent use, increase or cessation of medications, drugs, or alcohol
- Obtain history from friends, family, and treaters when possible
Physical Exam
Look for signs of a medical etiology:
- Vital signs
- General exam with particular attention to the signs and symptoms of toxidromes
- Neurologic exam, including cognitive exam
- Careful assessment for signs of delirium
Essential Workup
The workup is case specific and primarily based on the suspected etiology
Diagnostic Tests & Interpretation
Lab
- Electrolytes, BUN, creatinine, glucose, calcium
- Toxicology screen
- CBC with differential
- TSH
- Urinalysis
- Further specific studies should be guided by the suspected underlying etiologies
Imaging
- Head CT:
- Consider for new-onset psychotic symptom with features suggesting a nonpsychiatric etiology
- Will rule out intracranial hemorrhage
- MRI:
- If there is suspicion for intracranial pathology other than hemorrhage
Diagnostic Procedures/Surgery
When clinically warranted consider:
- Lumbar puncture
- ECG:
- Assess for QT prolongation
- Electroencephalogram:
- Consider with atypical psychosis to rule out complex partial seizures
- Findings may appear nonspecific or unremarkable even during active seizures
Differential Diagnosis
See Etiology
Initial Stabilization/Therapy
- Safety of patient and staff is paramount and may require presence of security
- Behavioral interventions should be used first
- Provide a calm, containing environment
- Remove all potentially dangerous items
- Use a reassuring voice and calm demeanor to set boundaries and verbally redirect
- If safety is a concern, patient needs to be under constant observation
- Offer medications by mouth before deciding to order restraints
- Physical or chemical restraints only if necessary to maintain safety of patient and staff
ED Treatment/Procedures
- If a nonpsychiatric etiology is suspected, identify and treat underlying medical condition
- Acute agitation is reduced with antipsychotics:
- Encourage voluntary PO medications prior to IM administration
- Avoid polypharmacy
- Rapid tranquilization may be achieved with the addition of a benzodiazepine
- Monitor for and treat adverse effects from antipsychotic medications:
- Extrapyramidal symptoms (dystonia, akathisia, pseudoparkinsonism, and tardive dyskinesia)
- Neuroleptic malignant syndrome is a life-threatening complication characterized by hyperthermia, muscle rigidity, autonomic instability, and altered consciousness
Medication
- Acute agitation leading to risk of harm to patient or others (give dose and repeat after 20-30 min if inadequate response)
- Haloperidol: 2-10 mg PO/IV/IM, repeat q20-60min p.r.n to max 100 mg/d; elderly 0.5-2 mg/dose
- Fluphenazine 2.5-10 mg PO/IM
- Aripiprazole: 2-15 mg PO/IM, max 30 mg/d
- Ziprasidone: 10-20 mg IM, max 40 mg/d. Caution: Monitor QT
- The above are commonly augmented with lorazepam 1-2 mg PO/IV/IM for sedation and either benztropine 0.5-1 mg or diphenhydramine 25-50 mg PO/IV/IM for prophylaxis against acute dystonia/akathisia
- Chlorpromazine: 25 mg PO/IM, repeat 25-50 mg q60min p.r.n to max 1,000 mg/d. Caution: Postural hypotension, avoid use in elderly
- Olanzapine: 2.5-20 mg PO/IM, may repeat dose q2-4h p.r.n to max 30 mg/d; elderly 2.5-5 mg/dose. Caution: Concurrent use of IM olanzapine and IV benzodiazepines may increase risk of cardiopulmonary collapse
- If no acute agitation and a primary psychiatric disorder is suspected, can initiate oral antipsychotic treatment in ED while psychiatric disposition is pending
- Catatonic symptoms require treatment with benzodiazepines
Geriatric Considerations |
| Antipsychotics carry a black box warning stating that elderly patients with dementia-related psychoses treated with antipsychotic drugs are at increased risk of death |
Pregnancy Prophylaxis |
| All antipsychotics are category C, except for clozapine which is category B. No teratogenic effects are known. Risk for neonatal adaptation syndrome. May increase risk of preterm birth, but no known effect on birth weight, neurodevelopmental outcomes, or neonatal mortality |
ALERT |
- Acute antipsychotic administration: Watch for acute dystonia (including laryngeal dystonia), acute akathisia, orthostasis
- Chronic administration: Late-onset movement disorders (dystonias, dyskinesia, Parkinsonism), weight gain, diabetes, hyperlipidemia
|
Disposition
Admission Criteria
- If nonpsychiatric etiology, admit to appropriate medical service
- If psychiatric etiology and patient is medically stable, patient may require admission to a psychiatric hospital if, due to psychosis, patient is:
- At risk of causing harm to self
- At risk of causing harm to others
- Gravely disabled and unable to care for self due to psychosis
- Criteria for involuntary commitment vary by state
Discharge Criteria
- Patient is not a danger to self or others and is able to perform activities of daily living
- Psychotic symptoms resolved after causative medical issue addressed and patient is medically stable for discharge
Issues for Referral
Psychiatric consultation is recommended if there is concern that patient is a danger to self or others, is unable to care for her/himself, or concern that psychosis is affecting medical decision making
Follow-up Recommendations
- If discharged, plan appropriate outpatient follow-up with medical and psychiatric providers. Consider referral to intensive outpatient or partial hospital program for acute symptoms not meeting criteria for hospitalization
- Consider referral for detoxification in patients with psychosis related to substance use
- BauerJO, StenborgD, LodahlT, et al. Treatment of agitation in the acute psychiatric setting. An observational study of the effectiveness of intramuscular psychotropic medication . Nord J Psychiatry. 2016;70:599-605.
- ByrneP. Managing the acute psychotic episode . BMJ. 2007;334:686-692.
- GarrigaM, PacchiarottiI, KasperS, et al. Assessment and management of agitation in psychiatry: Expert consensus . World J Biol Psychiatry. 2016;17(2):86-128.
- KorczakV, KirbyA, GunjaN. Chemical agents for the sedation of agitated agents in the ED: A systematic review . Am J Emerg Med. 2016;34:2426-2431.
- WilsonMP, PepperD, CurrierGW, et al. The psychopharmacology of agitation: Consensus statement of the American association for emergency psychiatry project Beta medical evaluation workgroup . West J Emerg Med. 2012;13(1):26-34.
See Also (Topic, Algorithm, Electronic Media Element)