Acute Psychosis

Essentials

• Psychotic behaviour is a symptom which reflects a distorted sense of reality and involves certain sensory functions or thought processes. Actual psychotic disorders have more extensive symptomatology and also certain criteria referring to the duration of the condition.
• Acute psychosis may develop secondary to a psychiatric or physical disease, medication or withdrawal symptoms.
• As concerns prognosis, treatment adherence is a more important factor than the speed at which psychotic symptoms are eliminated.
• Intoxication does not prevent the examination or referral of the patient, or admission for observation.

First-episode psychosis

• Possible somatic aetiology of the psychosis is investigated within primary care.
• Treatment of the actual psychosis should always take place by a specialist in psychiatry. Mental health teams specialising in the management of first-episode psychosis are available. These teams have flexible methods in evaluating the patient and expertise in assessing the urgency of the treatment needed.
• Meetings with the patient's family, and other members of his/her social network, are important, also when considering the aetiology and correct treatment. The aim is to
  • acquire information about the patient's background and symptoms
  • assist in the implementation of, and adherence to, treatment
  • deliver psychoeducation.

Somatic investigations in first-episode psychosis

• A somatic aetiology is suggested by abundant systemic symptoms (fever, headache, pains), rapid progression of symptoms without prodromal symptoms, or rapid fluctuation of symptoms, visual symptoms, olfactory hallucinations, motoric disturbances (spasticity, ataxia), catatonic symptoms, severe agitation, repeated head injuries (boxing, ice hockey), changes in the level of consciousness, rapid decrease of cognitive capacity and slurring of speech.
• In primary health care, a general examination should be carried out to rule out neurological conditions, substance abuse (structured questionnaires AUDIT Audit, DAST), prescription drug misuse, poisonings, infections and paraneoplastic symptoms.
• The first diagnostic basic investigations in an adult patient who does not have any somatic symptoms are: basic blood count including platelet count, CRP, clean voided urine, plasma potassium, sodium, calcium and glucose, ALT, gamma-glutamyl transferase (GGT), carbohydrate-deficient transferrin (CDT), plasma creatinine, urine drug screen, plasma TnT, ECG and a chest x-ray.
• If there is a specific reason to suspect somatic aetiology, consult a neurologist regarding the possibility of encephalitis and an internist to exclude endocrinological diseases and systemic autoimmune diseases.
• In the elderly, a memory disease and cerebrovascular disturbances in particular should always be excluded (MMSE, MRI).

Differential diagnosis in specialized care

• When the patient's behaviour changes rapidly, or a psychosis develops within less than 12 weeks, it is worthwhile to consider determining the anti-NMDA receptor antibodies and anti-VGKC antibodies.
• If a first-episode psychosis is associated with catatonic symptoms, if a severe psychiatric symptom develops within hours or days, or if a subacute psychiatric symptom is associated even with mild symptoms that resemble those of limbic encephalitis, a specialist in neurology should be consulted. Normal cranial MRI or EEG are not sufficient in these cases to exclude encephalitis.
• Family history, abnormalities in blood tests, slight deviations in appearance (xanthomas, marfanoid habitus) assist in charting rare hereditary diseases.

Psychiatric work up

• In an out-of-hours setting, evaluate particularly the patient's own illness awareness and treatment motivation; somatic aetiology; whether it is possible, with the help of support network, to safely manage until the next working day; agitation, state of excitement, potential aggressiveness and self-destructiveness.
• The more specific diagnosis is investigated within specialized health care.

1. The entire spectrum of psychotic symptoms must be charted.
   • Is the patient sensitive to sounds or light?
   • Does the patient hear things not heard by others, voices when left alone, a ticking sound etc. without an external stimulus?
   • Does the patient see lights, figures, creatures/insects, anything else abnormal?
   • Does the patient perceive smells that cannot be explained?
   • Are there odd bodily sensations?
   • Is the patient scared? Does the patient think that he/she is being followed or someone is trying to harm him/her?
   • Does the patient think he/she is a particularly important person? Does he/she feel that he/she possesses special powers?
   • Are there supernatural experiences?
   • The aetiology of psychosis cannot usually be based on the psychotic symptom picture alone.
2. The precipitating factor for the psychotic symptoms should be identified, as well as the duration and timing of the symptoms.
   • Short-term psychotic disorders, lasting for no more than a month, are usually triggered by major stressful events.
   • Schizophrenia can be diagnosed if psychotic symptoms have persisted for more than one month, and both the criteria for the disease and its exclusion criteria are fulfilled.
   • Substance-induced psychosis does not last for more than a week, usually only a few days, after the substance used has been withdrawn. If the psychotic symptoms persist for more than 2 weeks after substance withdrawal, the diagnosis is a primary psychotic disorder even if substance abuse, or co-existing sleep deprivation, was the initial precipitating factor.
   • Delirium: see Delirium in the Elderly Mental Disorders Due to Somatic Disease.
   • Delirium tremens (alcohol withdrawal delirium) is a medical emergency, which is preceded by very heavy alcohol consumption during several days Treatment of Alcohol Withdrawal.
   • Delusional disorder is associated with long-term but circumscribed psychotic thinking; the exact time of symptom onset may remain unclear.
     • For example, fear of a non-existing body deformity or disease, morbid jealousy, suspicion of being poisoned or exposed to radiation
     • The false beliefs are of long standing and persist despite any evidence to the contrary; however, other psychotic symptoms do not occur.
     • No hallucinations
   • The symptoms of a psychotic personality disorder include seclusiveness, bizarre thoughts or habits and narrowing life horizons. These characteristics have been present since the patient's youth, and they prevail in all life areas.
   • Dissociative disorder may resemble psychosis, and it should particularly be borne in mind if the patient has experienced serious mental trauma and the symptoms are related to emotional stress, evening time and being alone. The duration of symptoms is short as compared with true psychotic symptoms. Auditory hallucinations consist typically of unrecognized whispering, footsteps, clicks or snaps, etc.
3. The patient's mood must be identified.
   • Manic mood and symptoms can be encountered both in bipolar affective disorder and schizoaffective disorder.
   • Psychotic depression is often characterised by irrational feelings of guilt, plenty of somatic pains up to hypochondria, and, in some cases, the patient hears accusatory voices. In these cases, the patient should also always be asked about voices that encourage suicide. Psychotic depression is associated with major depression, bipolar affective disorder or schizoaffective disorder.

Rating scales

• The severity of manic episodes can be measured, for example, with the Young Mania Rating Scalehttp://www.bipsych.org/imgs/uploads/scales/BIPSYCH-Scales-Youngs-Mania-Rating-Scale.pdf.
• Depression scales suitable for the evaluation of depressive symptoms are the Beck Depression Inventory (BDI), the Calgary Depression Scale, the Montgomery-Åsberg Depression Rating Scale and CUDOS.
• The Mood Disorder Questionnaire (MDQ) can be used for screening a depressive person for bipolar affective disorder. If the screening result is positive, a careful diagnostic interview and usually also follow-up of mood are required because the test gives many false positive results.

Psychotic symptoms

• Symptoms characteristic of schizophreniform psychosis include auditory halluciations, in which the speech contains recognizable sentences and comments on what the patient does, or peculiar, strange trains of thought, such as that the patient is being spied on through hearing aids.
• Enhanced self-esteem and grandiosity suggest the patient may be manic.
• Incoherence: the patient's speech is unintelligible or confusing.
• Loose associations: the patient's speech is a sequence of unrelated ideas, it is difficult to follow the story and the relationships between the ideas are not apparent to the listener.
• Catatonia: a state of motor immobility, during which the patient's posture cannot be modified and the patient becomes unresponsive to speech. May also manifest as severe agitation, during which the patient is walking in place.
• Sidelong glances, watchfulness, suspiciousness, silence or whispering may be indicative of paranoia or auditory hallucinations.
• Concrete thinking: the patient does not refer to his/her emotions but only to events or things.
• Psychosis may also be characterized by the patient returning the question back to the interviewer or replying ”I don't know” or giving replies that are very short and unclear.
• Perception of a smell of rotting is a sign of psychotic depression or an epileptic seizure.
• The feeling of bugs walking on the skin and chasing of the bugs suggest delirium.
• In the elderly, severe depression is often accompanied with somatic delusions.

Initial drug therapy for psychotic symptoms

• Before starting antipsychotic medication, BMI, waist circumcerence, blood pressure and blood lipid values should be checked due to common metabolic adverse effects, and, due to rarer adverse effects, ECG, especially QT interval, basic blood count with platelets and ALT. Glucose tolerance test prior to starting the medication predicts well the medication-induced metabolic risk and is recommended when it is feasible to carry out.
• Other blood examinations to be performed, as necessary, are hCG (in female patients in fertile age) and, for the planning of pharmacotherapy, the genetic variations of enzymes involved in drug metabolism (e.g. CYP2D6, CYP1A2, etc.)
• The foremost aim is to ensure sleep and reduce anxiety; antipsychotics are not necessarily needed immediately to achieve these goals, should the patient resist their use.
• Antipsychotic medication can be started in primary care under careful monitoring.
• Antipsychotics are indicated straight away if the patient cannot sleep despite hypnotic medication or is restless, agitated or potentially aggressive or suicidal.
• The primary medication consists of those atypical antipsychotics (second generation antipsychotics) that have fewer metabolic adverse effects.
  • Their adverse effect profile is more favourable.
  • They are more effective for negative psychotic symptoms and cognitive disturbances.
• There are special features in the pharmacotherapy of children, adolescents, elderly and developmentally disabled persons, with regard to the required dose and sensitivity to adverse effects. In psychotic depression, merely an antidepressant may be sufficient for them.

Acute exacerbation of an existing psychotic disorder

• In a patient with psychosis, somatic illness, pain or e.g. constipation may manifest as worsening of psychotic symptoms. It may be difficult for the patient to describe the symptoms and, consequently, a careful somatic examination is always necessary.
• A patient with a history of previous antipsychotic medication will usually need higher doses than a patient with first-episode psychosis.
• Recurrent episodes of psychosis are usually treated with the medication that has proved beneficial in the past.
• Changing of long-term medication should only take place after consulting the physician who treats the patient in the outpatient setting.

Drug treatment in primary care

• Initial treatment
  • Aripiprazole 7.5 mg once daily, maintenance dose up to 30 mg
  • Ziprasidone 40 mg twice daily, maintenance dose up to 80 mg twice daily
  • Sertindole4 mg once daily, maintenance dose up to 20 mg
  • Asenapine 5 mg twice daily
  • Haloperidol 1 mg twice daily, maintenance dose up to 12 mg twice daily
  • Lurasidone 40-80 mg once daily
  • Cariprazine 1.5 mg once daily, maintenance dose up to 6 mg.
• More sedative, but, due to their metabolic adverse effects, not primary medications for maintenance therapy
  • Risperidone 0.5-2 mg once daily, maintenance dose up to 6 mg
  • Quetiapine 25-100 mg once daily, maintenance dose up to 800 mg
  • Olanzapine 5-10 mg once daily, maintenance dose up to 20 mg
• Should the condition remain inadequately controlled despite two of the above agents have been tried, clozapine should be considered: initial dose 25 mg daily, maintenance dose up to 900 mg Clozapine Therapy.
• Perphenazine, initially 4-8 mg once or twice daily, may be effective in delusional disorder and psychotic depression.
• In mood disorders, lithium or valproic acid, and in psychotic depression of bipolar disorder, lamotrigine, may be added to the medication.
• If the patient has overweight already prior to the medication or if his/her cardiovascular risk is elevated, initiate weight control interventions already in the beginning of the treatment. Investing in prevention of weight gain is worthwhile; reducing weight is much more difficult.
• Pharmacotherapy is required also in substance-induced psychosis, and treatment results are at their best when applying integrated treatment of the psychosis and the substance abuse problem. In substance-induced psychosis injectable medications may be more effective than orally administered ones.

Drug treatment in hospital

• To manage restlessness and anxiety
  • Diazepam 5-10 mg three times daily or lorazepam 1-2 mg three times daily by mouth Benzodiazepines Alone or in Combination with Antipsychotic Drugs for Acute Psychosis
  • Higher doses may be necessary if the patient has a history of excessive alcohol consumption or benzodiazepine abuse.
• To manage sleeplessness
  • The drug of choice is an antipsychotic with hypnotic properties.
  • If it is not possible to start antipsychotic medication immediately or adequate response is not achieved, melatonin 0.5-4 mg, zopiclone 7.5 mg, temazepam 20-40 mg or promazine 50-200 mg may be added to the regime.
• The criteria for choosing the therapeutic agent for the management of first-episode psychosis are the same as in primary care.
• If necessary, liquid or dispersible oral drugs can be used.
• The medicine will need to be administered by injection if
  • the patient spits out, or vomits, the drugs given by mouth
  • rapid sedation is necessary during seclusion or in order to avoid the use of seclusion.
• If seclusion is used, lorazepam 2-4 mg i.m. is often added to the antipsychotic medication.
• An administration of medication by injection against the will of the patient is an act against the individual's rights and is thus an exceptional procedure, which must be well reasoned in the medical notes.
• In delirious mania, only atypical antipsychotics should be used. Conventional antipsychotics will worsen confusion and restlessness.
• Delirium tremens is managed with a benzodiazepine administered every 1-2 hours until the patient falls asleep. The maximum dose of diazepam is 200 mg. If the patient is very restless or delirious, supplementary haloperidol 2.5-5 mg i.m. or i.v. may also be administered.
• Cerebral electrotherapy should be considered in the treatment of a catatonic patient or a patient with psychotic depression.

Contact in an acute situation

• Ensure the surroundings are sufficiently calm and safe.
• Invite family members or friends to accompany the patient to increase his/her feeling of safety. Too large number of people may, however, bother the patient.
• Avoid excessive physical closeness and sudden movements: a psychotic patient will see these as threatening.
• If the patient is on guard and keeps glancing around, ask if he/she is afraid of something and tell him/her that no one outside the room will be able to hear the discussion, all those present are bound by confidentiality etc.
• Clarify all unclear and confusing points. If something sounds odd, you can ask how this can be possible. What makes the patient so important that he/she is being followed?
• Do not enter into an argument with the patient about his/her experiences; an experience is always subjective. You may try to analyze the situation to the patient as an experience produced by the brain and his/her interpretation of it and as an emotional state. Of these, interpretation and emotion may be accepted and hence support the patient.
  • Experience: Tell the patient that insomnia is often associated with sensitization of the senses and false perceptions which originate from the brain and feel real, but they have no external stimuli. Information about the existence and character of psychotic symptoms on a general level will ease the patient's confusion and shame, and help him/her to broach his/her own symptoms.
  • Interpretation: It is natural that a human being tries to explain strange sensations in some way, psychotic explanations are distorted by the psychosis. You may, however, state that the patient's interpretation is not in accordance with the picture you have gotten or you observe.
  • Emotion: If the patient's emotional experience is e.g. fear, you may state that you know that the experience is true for the patient and that it must feel very frightening, which is why you would like to make him/her feel safer.
• If you notice that the patient becomes tense or raises his/her voice, interrupt the discussion in a friendly manner. Encourage the patient to calm down and describe how you see his/her present emotional state (”you appear disappointed with what I said”), and do not continue with the discussion until the situation has settled down. If the situation does not settle down, terminate the entire meeting for the time being.