II. Types

III. History

  1. History of Present Illness
    1. Age of onset of symptoms
    2. See Psychosis Symptoms
    3. Precipitating events
      1. Job or home stressors
      2. Substance Abuse
      3. Medical illness (e.g. fever, recent hospitalization)
      4. Occupational exposure
      5. STD exposure
  2. Psychiatric history
    1. See Primary psychosis
    2. Major Depression
    3. Bipolar Disorder
    4. Schizoaffective Disorder
    5. Schizophrenia
    6. Chemical Dependency
    7. Eating Disorder (e.g. Anorexia Nervosa, or Bulimia Nervosa) resulting in Malnutrition
    8. Post-Traumatic Stress Disorder (PTSD) or Posttraumatic Stress Disorder Triggers
  3. Medical History
    1. See Secondary Psychosis
    2. Pregnancy
    3. Electrolyte disturbance (e.g. Hyponatremia, Hypercalcemia)
    4. Endocrine or Metabolic disorders (e.g. Diabetes Mellitus, Thyroid Disease, Cushing Syndrome)
    5. Infectious Disease (e.g. HIV Infection, Syphilis, Encephalitis or Sepsis)
    6. B Vitamin Deficiency (e.g. Thiamine deficiency, Niacin Deficiency, Vitamin B12 Deficiency)
  4. Neurologic History
    1. Head Injury (e.g. Subdural Hematoma)
    2. Seizure Disorder
    3. Cerebrovascular Disease
    4. Headaches (new or increasing in intensity/characteristics)
    5. Multiple Sclerosis
    6. Dementia
    7. Parkinson Disease
    8. Brain Tumor

IV. Symptoms

V. Exam

  1. See Mental Status Exam
  2. See Psychosis Exam
  3. See Confusion Assessment Method (CAM, CAM-S)
  4. Vital Signs
  5. Complete Neurologic Exam
  6. General exam
    1. Evaluate for findings suggestive of organic cause

VI. Differential Diagnosis

  1. See Psychosis Differential Diagnosis
  2. See Schizophrenia Diagnosis
  3. Distinguish between Primary psychosis and Secondary Psychosis (Delirium)
    1. Primary psychosis (due to psychiatric disorders such as Schizophrenia or Bipolar Disorder)
      1. Auditory Hallucinations
      2. Young adult patient
      3. Gradual progression
      4. Cognitive disorders (prominent)
      5. Complicated Delusions
      6. Flat affect
      7. Intact orientation and consciousness
    2. Secondary Psychosis or Delirium (due to medical conditions, organic)
      1. Rapid onset of confusion
      2. Typically older patient (especially hospitalized, underlying cognitive deficits)
      3. Substances may also cause Delirium or Psychosis (see Drug Induced Psychosis)
        1. Drug Induced Psychosis is most common organic cause
      4. Visual Hallucinations are common
        1. Auditory Hallucinations suggest Primary psychosis
      5. Abnormal exam findings suggestive of drug-induced or organic cause
        1. Abnormal Vital Signs
        2. Aphasia
        3. Ataxia
        4. Cranial Nerve abnormalities

VII. Labs

VIII. Imaging

  1. Head imaging is not required for new onset Psychosis without focal neurologic deficit (expert opinion)
    1. Head imaging is based on clinical judgment
    2. (2017) Ann Emerg Med 69(4): 480-98 +PMID: 28335913 [PubMed]

IX. Management

  1. See Neuroleptic Medications
  2. See Schizophrenia
  3. Acute management of Psychosis (e.g. Schizophrenia or Mania) in the emergency department
    1. See Chemical Restraints
    2. Precautions
      1. See specific agents for potential for serious adverse effects (including QT Prolongation)
      2. Avoid using an Antipsychotic loading dose
      3. Response to Antipsychotics may be delayed by 2 or more days in acute mania
        1. Tohen (2000) Bipolar Disord 2(3 Pt 2): 261-8 [PubMed]
      4. Expect effects in Schizophrenia within 2 hours of Olanzapine dose
        1. Kapur (2005) Am J Psychiatry 162(5): 939-46 [PubMed]
    3. Medications
      1. Offer oral dose to patient first if conditions allow
      2. Olanzapine (Zyprexa)
        1. Initial: 10 mg sublingual wafer or 10 mg IM
        2. Next: 15 mg orally daily
      3. Risperidone
        1. Start 3 mg orally daily
    4. Other measures
      1. Attempt to listen to the patient (if the situation allows)
      2. Try to identify the patient's interests and find common goals
      3. Help the patient feel secure
      4. Allow the patient to make some decisions within a safe realm
    5. References
      1. Claudius, Behar and Charlton in Herbert (2014) EM:Rap 14(11): 2-3
      2. Zun, Swaminathan and Egan in Herbert (2014) EM:Rap 14(7): 11-13
      3. Osser (2001) Harvard Rev Psychiatry 9(3): 89-104 [PubMed]

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Ontology: Psychotic Disorders (C0033975)

Definition (MEDLINEPLUS)

Psychotic disorders are severe mental disorders that cause abnormal thinking and perceptions. People with psychoses lose touch with reality. Two of the main symptoms are delusions and hallucinations. Delusions are false beliefs, such as thinking that someone is plotting against you or that the TV is sending you secret messages. Hallucinations are false perceptions, such as hearing, seeing, or feeling something that is not there.

Schizophrenia is one type of psychotic disorder. People with bipolar disorder may also have psychotic symptoms. Other problems that can cause psychosis include alcohol and some drugs, brain tumors, brain infections, and stroke.

Treatment depends on the cause of the psychosis. It might involve drugs to control symptoms and talk therapy. Hospitalization is an option for serious cases where a person might be dangerous to himself or others.

Definition (NCI) A mental disorder characterized by personality change, impaired functioning, and loss of touch with reality.
Definition (NCI_CTCAE) A disorder characterized by personality change, impaired functioning, and loss of touch with reality. It may be a manifestation of schizophrenia, bipolar disorder or brain tumor.
Definition (NCI_NCI-GLOSS) A severe mental disorder in which a person loses the ability to recognize reality or relate to others. The person is not able to cope with the demands of everyday life. Symptoms include being paranoid, having false ideas about what is taking place or who one is, and seeing, hearing, or feeling things that are not there.
Definition (MSH) Disorders in which there is a loss of ego boundaries or a gross impairment in reality testing with delusions or prominent hallucinations. (From DSM-IV, 1994)
Definition (CSP) severest class of psychological disorders, characterized by one or more of severe affective disturbances, profound introspection, withdrawal from reality, hallucinations, or regression.
Concepts Mental or Behavioral Dysfunction (T048)
MSH D011618
ICD9 298.9, 290-299.99
SnomedCT 69322001, 192347006, 231483000
DSM4 298.9
LNC LA7534-6
English Psychotic disorder NOS, Atypical psychosis, Disorder, Psychotic, Disorders, Psychotic, Psychoses, Psychotic Disorder, Psychotic Disorders, Unspecified psychosis, PSYCHOSIS, Psychotic Disorder NOS, Psychosis NOS, PSYCHOTIC DIS, atypical psychosis (diagnosis), atypical psychosis, psychoses (diagnosis), psychoses, Psychotic Disorders [Disease/Finding], psychosis nos, psychotic disorders, mental disorder, psychotic disorder, psychotic disorder nos, Psychosis, Psychotic, [X]Psychosis NOS, [X] Psychosis NOS, psychosis, Psychotic disorder, Psychotic disorder (disorder), disorder; psychotic, psychotic; disorder, Psychosis, NOS, Psychotic disorder, NOS, PSYCHOSES, psychotic
French PSYCHOSE, Psychose SAI, Psychose atypique, Trouble psychotique SAI, Psychose non précisée, Psychose, Psychotique, Trouble psychotique, Psychoses, Troubles psychotiques
Spanish PSICOSIS, Psicosis NEOM, Psicótico, Psicosis atípica, Trastorno psicótico NEOM, Psicosis no especificada, psicosis atípica, psicosis, trastorno psicótico (trastorno), trastorno psicótico, Trastorno psicótico, Psicosis, Trastornos Psicóticos
Italian Disturbo psicotico, Psicosi non specificata, Disturbo psicotico NAS, Psicotico, Psicosi atipica, Psicosi aspecifica, Psicosi, Disturbi psicotici
Dutch niet-gespecificeerde psychose, psychose NAO, psychotische stoornis NAO, atypische psychose, psychose, psychotisch, psychotisch; stoornis, stoornis; psychotisch, psychotische stoornis, Psychosen, Psychotische stoornis, Psychotische stoornissen
German psychotisch, unspezifische Psychose, Psychose NNB, atypische Psychose, PSYCHOSE, Psychose, Psychosen, Psychotische Störungen
Portuguese Psicose NE, Psicose, Perturbação psicótica NE, Psicótico, Psicose atípica, PSICOSE, Perturbação psicótica, Psicoses, Transtornos Psicóticos
Japanese 精神病NOS, 精神病性, 非定型精神病, 精神病、詳細不明, 精神病性障害NOS, セイシンビョウセイ, セイシンビョウ, セイシンビョウセイショウガイNOS, ヒテイケイセイシンビョウ, セイシンビョウショウサイフメイ, セイシンビョウセイショウガイ, セイシンビョウNOS, 精神病-短期反応, 精神病性障害, 短期反応精神病, 精神病, 分裂感情障害, 精神分裂病型障害, 分裂情動障害
Swedish Psykotiska störningar
Czech psychotické poruchy, psychózy, Psychotická porucha NOS, Psychóza, Psychóza NOS, Psychotická porucha, Psychotický, Blíže neurčená psychóza, Atypická psychóza
Finnish Psykoottiset häiriöt
Croatian PSIHOZE
Polish Psychozy, Zaburzenie schizoafektywne, Zaburzenia psychotyczne
Hungarian Psychosis, Psychotikus, Psychotikus zavar k.m.n., Nem meghatározott psychosis, Psychosis k.m.n., Psychotikus zavar, Atypusos psychosis
Norwegian Psykotiske forstyrrelser, Psykoser

Ontology: Psychosis and psychotic disorders (SMQ) (C1963986)

Definition (MDRCZE) Pojem psychóza označuje duševní poruchu charakterizovanou značným zhoršením vztahu ke skutečnosti prokazovaným bludy, halucinacemi, znatelně inkoherentní mluvou, dezorganizovaným a neklidným chováním, obvykle bez zjevného uvědomění na straně pacienta. Pojem psychóza se také používá ve více všeobecném smyslu jako označení duševních poruch, při nichž jsou duševní funkce podstatně zhoršeny, takže značně narušují schopnost pacienta vyrovnávat se s běžnými požadavky života. Psychóza může být způsobena mnoha psychitarickými poruchami, jako je schizofrenie, schizoafektivní porucha, porucha spojená s bludy, krátká psychotická reakce, manie s psychózou, deprese s psychózou, demence a delirium. Psychóza je také spojena s některými nezákonnými drogami (kokainem, amfetaminem, atd.) a léky (agonisty dopaminu, I-dopou, psychostimulanty, atd.).U schizofrenie, schizofreniforní proruchy, schizoafektivní poruchy a krátké psychotické poruchy se pojem psychotický týká bludů, výrazných halucinací, dezorganizované mluvy nebo dezorganizovaného, případně katatonického chování.
Definition (MDRHUN) A psychosis valamely mentális zavarra utal, melyet erős leépülés jellemez, és amit a gyakorlatban a következők igazolnak: téveszmék, hallucinációk, feltűnően incoherens beszéd, dezorganizált és agitált viselkedés, ezeket a beteg rendszerint nem is érzékeli. A psychosis kifejezést általánosabb értelemben is használják olyan mentális betegség leírására, melyben a mentális funkciók jelentősen leromlottak és jelentősen zavarják a beteget a mindennapi élet szokásos követelményeinek történő megfelelésben. A psychosist számos psychiatriai betegség okozhatja, például: schizophrenia, schizoaffectiv betegség, téveszmés zavar, rövid psychotikus reactió, psychosissal kísért mánia, psychosissal kísért depressió, dementia, és delirium. Psychosist okozhatnak még: bizonyos tiltott kábítószerek (kokain, amphetamin stb.) és gyógyszerek (dopamin agonisták, l-dopa, psychostimulánsok stb.).A schizophrenia, schizophreniform zavar, schizoaffectiv betegség, és rövid psychotikus betegség esetében a psychoticus kifejezés téveszmékre, bármely prominens hallucinációra, dezorganizált beszédre, vagy dezorganizált, illetve catatoniás viselkedésre vonatkoznak.
Definition (MDR) Psychosis refers to a mental disorder characterized by gross impairment in reality testing evidenced by: delusions, hallucinations, markedly incoherent speech, disorganized and agitated behavior, usually without apparent awareness on the patient's part. Psychosis is also used in a more general sense to refer to mental disorders in which mental functioning is sufficiently impaired as to interfere grossly with patient's capacity to meet the ordinary demands of life. Psychosis can be caused by many psychiatric disorders such as: schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic reaction, mania with psychosis, depression with psychosis, dementia, and delirium. Psychosis is also associated with: certain illicit drugs (cocaine, amphetamine, etc.) and medications (dopamine agonists, l-dopa, psychostimulants, etc.). In schizophrenia, schizophreniform disorder, schizoaffective disorder, and brief psychotic disorder, the term psychotic refers to delusions, any prominent hallucinations, disorganized speech or disorganized or catatonic behavior.
Definition (MDRSPA) La psicosis se refiere a un trastorno mental caracterizado por un deterioro importante en el análisis de la realidad evidenciado por: delirios, alucinaciones, habla incoherente notoria, comportamiento desorganizado y agitado, por lo general sin que el paciente esté aparentemente consciente de ello. La psicosis se utiliza también en un sentido más general para referirse a los trastornos mentales en los cuales el funcionamiento mental está lo suficientemente deteriorado como para interferir de manera importante con la capacidad del paciente para enfrentar las exigencias normales de la vida. La psicosis puede ser causada por muchos trastornos psiquiátricos como: esquizofrenia, trastorno esquizoafectivo, trastorno delirante, reacción psicótica breve, manía con psicosis, depresión con psicosis, demencia y delirio. Además, la psicosis está asociada a: ciertas drogas ilegales (cocaína, anfetamina, etc.) y fármacos (agonistas de la dopamina, L-dopa, psicoestimulantes, etc.).En esquizofrenia, trastorno esquizofreniforme, trastorno esquizoafectivo y trastorno psicótico breve, el término psicótico se refiere a delirios, cualquier alucinación notoria, habla desorganizada o comportamiento desorganizado o catatónico.
Definition (MDRITA) La psicosi si riferisce ad un disturbo mentale caratterizzato da una grave compromissione dell'esame di realtà evidenziato da delirio, allucinazioni, linguaggio notevolmente incoerente, comportamento disorganizzato e agitato, di solito senza un'apparente consapevolezza da parte del paziente. Il termine psicosi viene anche usato in senso più generale con riferimento a disturbi mentali in cui la funzione mentale è sufficientemente compromessa nel senso che interferisce gravemente con la capacità del paziente di soddisfare gli ordinari requisiti della vita quotidiana. La psicosi può essere causata da molti disturbi psichiatrici fra cui schizofrenia, disturbo schizoaffettivo, disturbo delirante, disturbo psicotico breve, mania con psicosi, depressione con psicosi, demenza e delirio. La psicosi è anche associata ad alcune droghe illegali (cocaine, anfetamina, ecc.) e alcuni farmaci (dopamina agonisti, l-dopa, psicostimolanti, ecc.).Nella schizofrenia, nel disturbo schizoide, nel disturbo schizoaffettivo e nel disturbo psicotico breve, il termine psicotico si riferisce al delirio, a qualsiasi allucinazione prominente, al linguaggio disorganizzato e al comportamento disorganizzato e catatonico.
Definition (MDRFRE) Une psychose se réfère à un trouble mental qui se caractérise par une atteinte grave de la perception de la réalité mesurée par des tests faisant état de : délires, hallucinations et incohérence marquée du langage, comportement désorganisé et agité, généralement sans prise de conscience apparente de la part du patient Le terme « psychose » est également utilisé dans un sens plus large, en référence à des troubles mentaux dans lesquels la fonction mentale est suffisamment atteinte pour interférer de façon significative avec la capacité du patient à accomplir les activités du quotidien. Une psychose peut être causée par plusieurs affections psychiatriques, dont : schizophrénie, trouble schizo-affectif, trouble délirant, réaction psychotique brève, manie avec psychose, dépression avec psychose, démence et délire. La psychose et aussi associée à : Certaines drogues illicites (cocaïne, amphétamines, etc.) et certains médicaments (agonistes de la dopamine, l-dopa, psychostimulants, etc.).Dans le cadre de la schizophrénie, du trouble schizophréniforme, du trouble schizo-affectif et du trouble psychotique bref, le terme psychotique se rapporte à des délires, des hallucinations proéminentes, un langage désorganisé et un comportement désorganisé ou catatonique.
Definition (MDRDUT) Psychose verwijst naar een psychische stoornis die wordt gekenschetst door een grote gestoordheid in het testen van de werkelijkheid die blijkt uit: delusies, hallucinaties, uitgesproken incoherente spraak, gedesorganiseerd en geagiteerd gedrag, gewoonlijk zonder dat de patiënt zich daar blijkbaar van bewust is. Psychose wordt ook gebruikt in een algemenere zin om te verwijzen naar geestesziekten waarbij het geestelijk functioneren voldoende is gestoord dat dit het vermogen van de patiënt om aan de gewone levenseisen te voldoen in hoge mate verstoort. Psychose kan worden veroorzaakt door vele psychische stoornissen zoals: schizofrenie, schizo-affectieve stoornis, delusiestoornis, kortdurende psychotische reactie, manie met psychose, depressie met psychose, dementie en delirium. Psychose gaat ook gepaard met: bepaalde illegale drugs (cocaïne, amfetamine enz.) en medicaties (dopamine-agonisten, I-dopa, psychostimulantia enz.).Bij schizofrenie, schizofreniforme stoornis, schizo-affectieve stoornis en kortdurende psychotische reactie verwijst de term psychotisch naar delusies, prominente hallucinaties, gedesorganiseerde spraak of gedesorganiseerd of catatonisch gedrag.
Definition (MDRGER) Psychose bezieht sich auf eine psychische Erkrankung, die durch eine schwere Beeinträchtigung des Realitätsbewusstseins gekennzeichnet und durch Folgende nachweisbar ist: Delusionen, Halluzinationen, auffällig wirre Sprache, desorganisiertes und agitiertes Verhalten, gewöhnlich ohne ersichtliches Bewusstseins seitens des Patienten. Psychose wird auch im allgemeineren Sinn zur Bezeichnung von Geistesstörungen verwendet, wobei die Geistesfunktion ausreichend genug beeinträchtigt ist, dass dies die Fähigkeit des Patienten stört, die gewöhnlichen Anforderungen des Lebens zu bewältigen. Psychose kann von vielen psychiatrischen Erkrankungen hervorgerufen werden, wie: Schizophrenie, schizoaffektive Störungen, Wahnstörungen, kurze psychotische Reaktion, Manie mit Psychose, Depression mit Psychose, Demenz, Delirium. Psychose wird ebenfalls mit Folgenden in Verbindung gebracht: Bestimmte illegale Drogen (Kokain, Amphetamin, usw.) Medikamente (Dopaminagonisten, l-Dopa, Psychostimulanzien, usw.).Bei Schizophrenie, schizophrenieähnlicher Stoerung, schizoaffektiver Störung und kurzer psychotischer Störung bezieht sich der Begriff „psychotisch" auf Delusionen, alle auffallenden Halluzinationen, verwirrte Sprache bzw. auf desorganisiertes oder katatonisches Verhalten.
Definition (MDRPOR) A psicose refere-se a uma perturbação mental caracterizada por uma grande deficiência da análise da realidade evidenciada por: delírios, alucinações, fala marcadamente incoerente, comportamento desorganizado e agitado, geralmente sem que o doente esteja aparentemente consciente. A psicose também é utilizada num sentido mais geral, para se referir a perturbações mentais em que o funcionamento mental está suficientemente deteriorado para interferir grandemente com a capacidade do doente para satisfazer as solicitações habituais da vida. A psicose pode ser causada por muitas perturbações psiquiátricas tais como: esquizofrenia, perturbação esquizoafectiva, perturbação delirante, reacção psicótica breve, mania com psicose, depressão com psicose, demência, e delírio. A psicose também está relacionada com: drogas ilícitas (cocaína, anfetaminas, etc.) e medicamentos (antagonistas da dopamina, L-dopa, psicoestimulantes, etc.).Na esquizofrenia, perturbação esquizofreniforme, perturbação esquizoafectiva e perturbação psicótica breve, o termo psicótico refere-se a delírios, quaisquer alucinações importantes, fala desorganizada, ou comportamento catatónico ou desorganizado.
Definition (MDRJPN) 精神病は、通常は患者に明確な認識のない、妄想、幻覚、著しい思考散乱性言語、解体・興奮行動などで証明される、現実検討における著しい不全状態を特徴とする精神障害のことである。精神病はまた、より一般的な意味で、日常生活の必要性を満たすための患者の能力が著しく阻害されるほど、精神機能が著しく損なわれている精神障害に関しても用いられる。精神病は、統合失調症、統合失調感情障害、妄想性障害、一時的精神病性反応、精神病を伴う躁病、精神病を伴ううつ病、認知症および譫妄などの多くの精神障害により生じる。精神病は一部の違法薬物(コカイン、アンフェタミンなど)および医薬品の服用(ドパミン作動薬、レボドパ、精神興奮薬など)によっても生じる。統合失調症、統合失調症様障害、統合失調感情障害および一時精神病性障害においては、精神病性という用語は、妄想、顕著な幻覚、解体した会話、または解体あるいは緊張病性行動を意味する。
Concepts Classification (T185)
English Psychosis and psychotic disorders (SMQ)
Spanish Psicosis y trastornos psicóticos (SMQ)
French Psychose et troubles psychotiques (SMQ)
Portuguese Psicose e perturbações psicóticas (SMQ)
German Psychose und psychotische Erkrankungen (SMQ)
Italian Psicosi e disturbi psicotici (SMQ)
Czech Psychóza a psychotické poruchy (SMQ)
Japanese 精神病および精神病性障害(SMQ)
Dutch Psychose en psychotische aandoeningen (SMQ)
Hungarian Psychosis és psychotikus rendellenességek (SMQ)