Author:
Eric C.Hyder
Laura J.Macnow
Description
Mental derangement involving hallucinations, delusions, or grossly disorganized behavior resulting in loss of contact with reality
- Complex and poorly understood pathophysiology
- An excess in dopaminergic signaling may be a contributing factor
- Psychosis ranges from a relatively mild derangement to catatonia
- CNS impairment leading to a psychotic presentation may be due to:
- Neurologic disorders
- Metabolic conditions
- Toxins or drug effects
- Infections
- Higher risk for underlying psychiatric disorder:
- Hallucinations and illusions incorporated into delusional system
- Late adolescence/early adulthood
- Normal orientation
- Higher risk for underlying medical disorder:
- Middle- to late-life presentation
- Acute onset
- History of substance abuse
- No pre-existing psychiatric history
- Absence of a family history of major mental illness
- Presence of pre-existing medical disorders
- Lower socioeconomic level
- Recent memory loss
- Disorientation or distractibility
- Abnormal vital signs
- Visual hallucinations:
- Delirium
- Dementia
- Migraines
- Dopamine agonist therapy (i.e., carbidopa)
- Posterior cerebral infarcts
- Narcolepsy
Etiology
- Neurologic:
- Head trauma
- Space-occupying lesions
- Cerebrovascular accident
- Seizure disorders
- Hydrocephalus
- Neuropsychiatric disorders (Parkinson, Huntington, Alzheimer, Pick, Wilson disease)
- Infectious:
- Focal infections in the elderly (UTI, pneumonia)
- HIV
- Neurosyphilis
- Encephalitis
- Lyme disease: Neuroborreliosis
- Parasites:
- Cerebral malaria
- Neurocysticercosis
- Schistosomiasis
- Toxoplasmosis
- Trypanosomiasis
- Metabolic:
- Electrolyte imbalance
- Hypoglycemia
- Hypoxia
- Porphyria
- Withdrawal syndromes
- Endocrine:
- Thyroid disorders
- Parathyroid disorders
- Diabetes mellitus
- Pituitary abnormalities
- Adrenal abnormalities
- End-organ failure:
- Cardiac/respiratory
- Renal
- Hepatic
- Nutritional deficiencies:
- Pernicious anemia
- Wernicke-Korsakoff syndrome
- Pellagra
- Pyridoxine deficiency
- Autoimmune disorders:
- Systemic lupus erythematosus
- Sarcoidosis
- Myasthenia gravis
- Paraneoplastic syndromes
- Demyelinating disease:
- Multiple sclerosis
- Leukodystrophies
- Postoperative states:
- Intoxicants:
- Alcohol
- Benzodiazepines
- Barbiturates
- Stimulants (cocaine, amphetamines)
- Hallucinogens
- Opiates
- Anticholinergic compounds
- Inhalants
- Cannabis/synthetic cannabinoids
- Toxins:
- Bromide
- Carbon monoxide
- Heavy metals
- Organophosphates
- Medication side effects:
- Corticosteroids
- Anticholinergics
- Sedative-hypnotics
- Psychiatric:
- Antidepressants
- Antipsychotics
- Lithium carbonate
- Antiparkinsonian drugs
- Anticonvulsants
- Antibiotics (quinolones, isoniazid)
- Antihypertensive agents
- Cardiac (digitalis, lidocaine, propranolol, procainamide)
- Interferon
- Muscle relaxants
- Over-the-counter medications:
- Psychiatric:
- Schizophrenia
- Schizoaffective disorder
- Delusional disorder
- Bipolar disorder with psychotic features
- Major depression with psychotic features
- Stress reactions including posttraumatic stress disorder
- Narcolepsy (hallucinations at edge of sleep/wake cycle)
- Postpartum psychosis
Signs and Symptoms
- Psychosis characterized by:
- Impaired reality testing
- Inappropriate affect
- Poor impulse control
- Focal and diffuse CNS impairment may result in derangements of:
- Perception
- Thought content
- Thought process
- Hallucinations:
- Sensory perception that has the compelling sense of reality of a true perception without external stimulation of the relevant sensory organ
- Delusions:
- Beliefs held with certainty, incorrigibility, and impossibility
- Categorized by type and theme:
- Bizarre or nonbizarre
- Mood congruent or neutral
- Persecutory or grand iose
- Primary or secondary
- Thought disorder
- Affective symptoms may include mania, depression, or catatonia
History
- Time course: Acute, episodic, chronic
- Collateral from family or outpatient providers
- Substance use
- Medications and medication adherence
- Family history
- Associated symptoms: Fever, weight loss, appetite, recent surgery, and trauma
Physical Exam
- Vital signs
- Neurologic exam:
- Cognitive exam: Attention and orientation
- Motor exam: Tone, abnormal movements
Essential Workup
Detailed history and physical exam, including neurologic exam
Diagnostic Tests & Interpretation
Lab
- Low likelihood of clinically significant findings if there is a past history of psychosis, a benign history, and normal physical exam
- First line:
- CBC
- Electrolytes including calcium, BUN/creatinine, glucose
- Urine and serum toxicology screen
- Urinalysis
- Liver function tests
- Thyroid function tests
- Vitamin B12 and folate
- Second line guided by history and physical findings:
- Ammonia level
- HIV testing
- Fluorescent treponemal antibody absorption (to rule out neurosyphilis; rapid plasmin reagin not sufficient as screen)
- Ceruloplasmin
- Urine heavy metals
- ESR, C-reactive protein, antinuclear antibody
Imaging
- Routine CT or MRI scans are of little benefit
- Indications:
- History or exam suggests a neurologic disorder
- First-episode psychosis, 50 yr and older
- No clear clinically relevant benefit for MRI over CT
Diagnostic Procedures/Surgery
- ECG with attention to corrected QT interval
- Not recommended for routine screening:
Differential Diagnosis
- Martha Mitchell effect:
- Process by which a clinician mistakes the patient's perception of real events as delusional
- Locked-in syndrome
- Periodic paralysis
- Conversion disorder
Prehospital
- Ensure safety of patient, bystand ers, and medical personnel
- Monitor vital signs, check finger stick
Initial Stabilization/Therapy
- Safety
- Evaluation
- Check O2 saturation and serum glucose
- If uncooperative and dangerous, control behavior
ED Treatment/Procedures
- Treat underlying medical illness or substance abuse disorder
- Control psychotic behavior with psychotropic medications
- Check for prolonged QT before administering neuroleptic agents
- Haloperidol in combination with lorazepam:
- Safe, fast; least disruptive of ongoing medical exam of patient
- Atypical neuroleptics:
Medication
First Line
Haloperidol 2-10 mg IM/IV with lorazepam 0.5-2 mg IM/IV
Second Line
- Neuroleptics:
- Benzodiazepines:
- Dissociatives:
Geriatric Considerations |
Increased mortality risk in patients >65 yr on typical and atypical antipsychotics- Start with lower doses (haloperidol 2 mg IV, olanzapine 2.5-5 mg PO/SL/IM)
- Use benzodiazepines cautiously, given risk of disinhibition; avoid in delirious patients
|
Pregnancy Prophylaxis |
| Best evidence of safety of antipsychotic use in pregnancy is for first-generation (typical) antipsychotics such as haloperidol |
Disposition
Admission Criteria
- If primarily medical etiology, admission to medical service, criteria dictated by specific medical condition
- If primarily psychiatric etiology (e.g., schizophrenia), admit to psychiatric service if:
- Danger to self or others
- Inability to care for self
- Deranged thought pattern that can be threat to self or others
- First episode: Evaluation and stabilization
- Laws for involuntary hospitalization vary by state
Discharge Criteria
- Stable medical condition
- Not suicidal/homicidal
- Able to care for self
- Capable of making medical decisions
Issues for Referral
- Insurance coverage determines inpatient and outpatient psychiatric disposition options
- Case management or social services necessary for psychiatric disposition
Follow-up Recommendations
- If psychosis is primarily psychiatric, confirm follow-up appointment with mental health provider within 1-2 wk
- Reassess risk/benefit of continuing on antipsychotic medication at follow-up
- FraserS, HidesL, PhilipsL, et al. Differentiating first episode substance induced and primary psychotic disorders with concurrent substance use in young people . Schizophr Res. 2012;136:110-115.
- FreudenreichO, SchulzSC, GoffDC. Initial work-up of a first-episode psychosis: A conceptual review . Early Interv Psychiatry. 2009;3:10-18.
- GouletK, DeschampsB, EvoyF, et al. Use of brain imaging (computed tomography and magnetic resonance imaging) in first-episode psychosis: Review and retrospective study . Can J Psychiatry. 2009;54:493-501.
- RiddellJ, TranA, BengiaminR, et al. Ketamine as a first-line treatment for severely agitated emergency department patients . Am J Emerg Med. 2017;35:1000-1004.
- WilsonMP, PepperD, CurrierGW, et al. The psychopharmacology of agitation: Consensus statement of the American association for emergency psychiatry project BETA psychopharmacology workgroup . West J Emerg Med. 2012;13:26-34.
See Also (Topic, Algorithm, Electronic Media Element)