Signs and Symptoms
Criteria of the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5)
- At least 2 of the following symptoms most of the time for 1 mo:
- Delusions (fixed, false beliefs):
- Bizarre, paranoid, or grand iose
- Often persecutory, religious, or somatic content
- Hallucinations:
- Commonly auditory but may involve any sensory modality
- Thought disorder:
- Disorganized speech ranging from odd, idiosyncratic logic to incoherence
- Grossly disorganized or catatonic behavior
- Negative symptoms:
- Apathy and amotivation
- Flat affect
- Social isolation
- Anhedonia
- Diminished speech and emotional expression
- Disturbance of at least one major area of functioning: School, work, interpersonal relationships, self-care
- Continuous signs of the disturbance persist for at least 6 mo
Essential Workup
- Complete general and neurologic exam including vital signs and mental status exam
- Screen for psychosis:
- Delusions:
- “Do you feel anyone is trying to harm you or that you are being followed?”
- “Is anyone trying to send you messages, steal, control, or block your thinking?”
- 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 others?”
- “Do you ever hear voices that comment on your behavior?”
- Evaluate potential dangerousness to self or others:
- Screen for past violence or self-injury
- Content of psychotic symptoms should be explored to assess safety
- “Have you needed to protect yourself or others? If so, how?”
- Patient history and medication adherence may be unreliable. Obtain collateral history from additional sources:
- Friends and family
- Treaters (PCP, therapist, psychiatrist)
- Pharmacy
- Evaluate for affective psychosis (mania, major depression, or schizoaffective disorder)
- Evaluate for delirium or dementia
- Assess for drug-induced psychosis (see “Psychosis, Acute”)
- Psychosis due to medical etiology should be ruled out
Diagnostic Tests & Interpretation
Lab
- Toxicology screen
- Electrolytes, BUN, creatinine, glucose, calcium
- CBC with differential
- TSH
- Urinalysis
Imaging
Consider head imaging for new-onset psychosis of undetermined etiology or new-onset neurologic symptoms
Diagnostic Procedures/Surgery
ECG to monitor QTc interval
Differential Diagnosis
- Delirium
- Substance-induced psychosis
- Alcohol or sedative/hypnotic withdrawal
- Psychosis secondary to general medical conditions such as TLE, MS, LBD, thyrotoxicosis, CVA, DM
- Bipolar disorder
- Major depression with psychotic features
- Schizoaffective disorder:
- Schizophrenia with prominent depressive and /or manic symptoms during psychosis
- Delusional disorder
- Schizotypal personality disorder
- Brief psychotic episode:
- Similar symptoms, duration of <1 mo
- Schizophreniform disorder:
- Similar symptoms, duration between 1 and 6 mo
- Catatonia
Prehospital
- Patients may be paranoid and confused about need for evaluation due to impaired insight
- Patients may require police presence with verbal de-escalation or restraints to maintain safety
- Risk of mortality is 3× higher for patients who require legal intervention compared to general population
- State laws vary as they apply to involuntary emergency evaluation. Criteria may include any one of the following:
- Risk of imminent harm to self
- Risk of imminent harm to others
- Inability to care for self in the community
Initial Stabilization/Therapy
- Safety of patient and staff is paramount; security presence may be required
- If patient presents with paranoia or agitation, behavioral interventions should be first line:
- Provide a calm, low-stimulation environment
- Remove potentially dangerous items from the patient's room
- Use a reassuring voice and calm demeanor to set boundaries and verbally redirect the patient if needed
- Provide constant observation if there is a concern for safety
- Physical and /or chemical restraints may be necessary for treatment of the acutely agitated patient
- Acute agitation may be treated with antipsychotics or benzodiazepines or both in combination
- Encourage voluntary PO meds prior to IM administration
- IM benzodiazepines include: Lorazepam, midazolam
- IM antipsychotics include: Haloperidol, olanzapine, chlorpromazine (monitor orthostatics), ziprasidone (monitor QTc), and aripiprazole
- Haloperidol PO/IV/IM can be augmented with lorazepam PO/IV/IM
- IM olanzapine should not be combined with IM/IV benzodiazepines as this increases risk of cardiopulmonary collapse
ED Treatment/Procedures
- Psychiatric consultation in cases of decompensated schizophrenia
- Antipsychotic medications are the mainstay of treatment
- High-potency typical antipsychotic agents:
- Associated with less QTc prolongation
- Higher propensity for extrapyramidal symptoms:
- Dystonia
- Parkinsonism
- Akathisia
- Tardive dyskinesia
- IV haloperidol associated with fewer extrapyramidal symptoms than PO/IM and higher risk of QTc prolongation (monitor)
- Low-potency typical antipsychotics:
- Higher risk of QTc prolongation
- Fewer extrapyramidal symptoms
- More sedating
- Orthostatic hypotension (monitor)
- Anticholinergic side effects
- Lower seizure threshold
- Atypical antipsychotic agents:
- Better tolerated with less EPS
- Associated with metabolic syndrome and weight gain
- Can cause orthostatic hypotension
- Nearly all antipsychotics can increase QTc:
- More likely (ziprasidone)
- Less likely (aripiprazole)
- Risk of sleep walking and sleep-related eating disorder
- Clozapine is the only antipsychotic that is clearly more effective for reducing psychotic symptoms and suicide risk:
- Requires close monitoring of WBC and ANC due to risk of agranulocytosis
- Highly sedating, hypotensive, lowers seizure threshold
- Can cause QTc prolongation, myocarditis, and cardiomyopathy
- Long-acting antipsychotic preparations (given q2wk-3mo) include:
- If a high-potency conventional antipsychotic agent is initiated, patients younger than age 40 can be started on benztropine (Cogentin) 2 mg b.i.d for 10 d to reduce the risk of dystonic reactions
Medication
- Typical antipsychotics (first generation):
- High potency:
- Haloperidol 0.5-100 mg/d. Acute agitation 2.5-10 mg PO/IV/IM. Repeat q20-60min as needed
- Fluphenazine 10 mg/d
- Thiothixene 1-30 mg/d
- Medium potency:
- Low potency:
- Chlorpromazine 50-200 mg/d in 3 div doses
- Loxapine 5-100 mg/d
- Thioridazine 50-800 mg/d in 2-3 div doses
- Atypical antipsychotics (second generation):
- Aripiprazole 5-30 mg/d
- Asenapine 5-20 mg/d (SL)
- Clozapine 12.5-900 mg/d
- Iloperidone 1-24 mg/d
- Lurasidone 20-160 mg/d
- Olanzapine 5-20 mg/d
- Paliperidone 6-12 mg/d
- Quetiapine 25-800 mg/d
- Risperidone 1-16 mg/d
- Ziprasidone 20-160 mg/d
- Benzodiazepines:
- Lorazepam (Ativan) 0.5-2 mg per dose augments antipsychotic for acute agitation
Geriatric Considerations |
| Black box warning: Elderly patients with dementia-related psychoses treated with antipsychotic drugs are at increased risk of death. |
Disposition
Admission Criteria
- Admit to inpatient psychiatric hospital, if patient is medically stable and :
- Is a danger to self or others
- Is gravely disabled and unable to care for himself due to psychosis
- Has new-onset psychosis and medical etiology has been ruled out
- Prior to transfer to psychiatric facility, patient must have acute medical and surgical issues addressed
- Criteria for involuntary psychiatric hospitalization vary by state
Discharge Criteria
- Patient is not a danger to self or others and is able to perform activities of daily living
- Psychiatric follow-up is arranged
- Psychotic symptoms may persist at time of discharge
Follow-up Recommendations
- Outpatient psychopharmacologic follow-up should occur within 1 wk of discharge
- Patients taking antipsychotics (especially atypicals) should be monitored for QTc prolongation and for obesity and related metabolic syndromes
- Adjunctive cognitive behavioral therapy and other psychosocial treatments can help patients manage psychotic symptoms and improve medication adherence
- Discuss smoking cessation and referral:
- 2/3 of patients with schizophrenia smoke tobacco
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.Arlington, VA: American Psychiatric Publishing; 2013.
- BuckleyP, CitromeL, NichitaC, et al. Psychopharmacology of aggression in schizophrenia . Schizophr Bull. 2011;37:930-936.
- OlfsonM, GerhardT, HuangC, et al. Premature mortality among adults with schizophrenia in the United States . JAMA Psychiatry. 2015;72:1172-1181.
- SekarA, BialasAR, de RiveraH, et al. Schizophrenia risk from complex variation of complement component 4 . Nature. 2016;530:177-183.
- van OsJ, KapurS. Schizophrenia . Lancet. 2009;374:635-645.
See Also (Topic, Algorithm, Electronic Media Element)
The authors gratefully acknowledge Celeste N. Nadal and Melissa P. Bui for their contribution to the previous edition of this chapter.