II. Epidemiology
- Onset (first Psychosis episode)
- Males in early to mid-20s
- Females in late 20s
III. History
- History of Present Illness
- Age of onset of symptoms
- See Psychosis Symptoms
- Precipitating events
- Job or home stressors
- Substance Abuse
- Medical illness (e.g. fever, recent hospitalization)
- Occupational exposure
- STD exposure
- Psychiatric history
- See Primary psychosis
- Major Depression
- Bipolar Disorder
- Schizoaffective Disorder
- Schizophrenia
- Chemical Dependency
- Eating Disorder (e.g. Anorexia Nervosa, or Bulimia Nervosa) resulting in Malnutrition
- Post-Traumatic Stress Disorder (PTSD) or Posttraumatic Stress Disorder Triggers
- Medical History
- See Secondary Psychosis
- Pregnancy
- Electrolyte disturbance (e.g. Hyponatremia, Hypercalcemia)
- Endocrine or Metabolic disorders (e.g. Diabetes Mellitus, Thyroid Disease, Cushing Syndrome)
- Infectious Disease (e.g. HIV Infection, Syphilis, Encephalitis or Sepsis)
- B Vitamin Deficiency (e.g. Thiamine deficiency, Niacin Deficiency, Vitamin B12 Deficiency)
- Neurologic History
- Head Injury (e.g. Subdural Hematoma)
- Seizure Disorder
- Cerebrovascular Disease
- Headaches (new or increasing in intensity/characteristics)
- Multiple Sclerosis
- Dementia
- Parkinson Disease
- Brain Tumor
IV. Types
- See Psychosis Types
V. Symptoms
VI. Exam
- See Mental Status Exam
- See Psychosis Exam
- See Confusion Assessment Method (CAM, CAM-S)
- Vital Signs
- Complete Neurologic Exam
-
General exam
- Evaluate for findings suggestive of organic cause
VII. Differential Diagnosis
- See Psychosis Differential Diagnosis
- See Schizophrenia Diagnosis
- Distinguish between Primary psychosis and Secondary Psychosis (Delirium)
- Primary psychosis (due to psychiatric disorders such as Schizophrenia or Bipolar Disorder)
- Auditory Hallucinations
- Young adult patient
- Gradual progression
- Cognitive disorders (prominent)
- Complicated Delusions
- Flat affect
- Intact orientation and consciousness
- Secondary Psychosis or Delirium (due to medical conditions, organic)
- Rapid onset of confusion
- Typically older patient (especially hospitalized, underlying cognitive deficits)
- Substances may also cause Delirium or Psychosis (see Drug Induced Psychosis)
- Drug Induced Psychosis is most common organic cause
- Visual Hallucinations are common
- Auditory Hallucinations suggest Primary psychosis
- Abnormal exam findings suggestive of drug-induced or organic cause
- Abnormal Vital Signs
- Aphasia
- Ataxia
- Cranial Nerve abnormalities
- Primary psychosis (due to psychiatric disorders such as Schizophrenia or Bipolar Disorder)
VIII. Labs
- See Psychosis Labs
IX. Imaging
- Head imaging is not required for new onset Psychosis without focal neurologic deficit (expert opinion)
- Head imaging is based on clinical judgment
- (2017) Ann Emerg Med 69(4): 480-98 +PMID: 28335913 [PubMed]
X. Management
- See Neuroleptic Medications
- See Schizophrenia
- Acute management of Psychosis (e.g. Schizophrenia or Mania) in the emergency department
- See Chemical Restraints
- Precautions
- See specific agents for potential for serious adverse effects (including QT Prolongation)
- Avoid using an Antipsychotic loading dose
- Response to Antipsychotics may be delayed by 2 or more days in acute mania
- Expect effects in Schizophrenia within 2 hours of Olanzapine dose
- Medications
- Offer oral dose to patient first if conditions allow
- Olanzapine (Zyprexa)
- Initial: 10 mg sublingual wafer or 10 mg IM
- Next: 15 mg orally daily
- Risperidone
- Start 3 mg orally daily
- Other measures
- Attempt to listen to the patient (if the situation allows)
- Try to identify the patient's interests and find common goals
- Help the patient feel secure
- Allow the patient to make some decisions within a safe realm
- References
- Claudius, Behar and Charlton in Herbert (2014) EM:Rap 14(11): 2-3
- Zun, Swaminathan and Egan in Herbert (2014) EM:Rap 14(7): 11-13
- Osser (2001) Harvard Rev Psychiatry 9(3): 89-104 [PubMed]