Psychosis

Aka: Psychosis, Psychotic Disorder, Acute Psychosis

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II. Definitions

  1. Psychosis
    1. Psychosis characterized by personality change, paranoia, impaired functioning, and loss of touch with reality
  2. Delirium
    1. Altered Level of Consciousness
    2. Reduced clarity and environmental awareness
    3. Reduced ability to focus or to sustain or shift attention

III. Epidemiology

  1. Acute Psychosis accounts for 53 in 1000 emergency department visits in U.S. (CDC 2017-19)

IV. History

  1. History of Present Illness
    1. Age of onset of symptoms
    2. When were Psychosis Symptoms first noted?
    3. From what environment did the patient present for today'd evaluation?
    4. What medications or substances were known to have been taken today before the evaluation?
    5. See Psychosis Symptoms
    6. 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. Medications
    1. See Drug Induced Psychosis
    2. See Toxin Induced Altered Level of Consciousness Causes
    3. See Medication Causes of Delirium in the Elderly
    4. See Medications to Avoid in Older Adults
    5. See Date Rape Drug
  3. 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
  4. 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)
  5. 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

V. Types

  1. See Psychosis Types

VI. Symptoms

  1. See Psychosis Symptoms

VII. Exam

  1. Vital Signs
    1. Obtain full Vital Signs including Body Temperature, Blood Pressure, Heart Rate, Respiratory Rate and Oxygen Saturation
    2. See Toxin Induced Vital Sign Changes
  2. Mental Status
    1. See Mental Status Exam
    2. See Psychosis Exam
    3. See Confusion Assessment Method (CAM, CAM-S)
  3. Complete Neurologic Exam
    1. See Altered Level of Consciousness
    2. See Toxin Induced Neurologic Changes
    3. See Drug Induced Seizure
  4. Eye Exam
    1. See Substance-Induced Eye Findings
    2. See Pupil Constriction (Miosis)
    3. See Pupil Dilation (Mydriasis)
  5. General exam
    1. Evaluate for findings suggestive of organic cause
    2. See Toxin Induced Skin Changes
    3. See Toxin Induced Odors
    4. Meningeal signs (e.g. Nuchal Rigidity)
    5. Thyroid exam (e.g. toxic Goiter)

VIII. 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, consciousness and Short Term Memory
    2. Secondary Psychosis or Delirium (due to medical conditions, organic)
      1. Rapid onset of confusion
      2. Typically older patient (especially hospitalized, underlying cognitive deficits)
        1. Delirium is commonly missed (esp. age 65 years)
      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. Short Term Memory is typically lost in acute Delirium
        1. Contrast with Psychosis, in which Short Term Memory is retained
      6. Delirium is associated with acute gross cognitive deficits
        1. Psychosis however may have chronic deficits (e.g. Learning Disability) worsened by acute event
      7. Abnormal exam findings suggestive of drug-induced or organic cause
        1. Abnormal Vital Signs
        2. Aphasia
        3. Ataxia
        4. Cranial Nerve abnormalities
        5. Fever
        6. Intermittent (or waxing or waning symptoms)

IX. Labs

  1. See Psychosis Labs
  2. Finger-stick bedside Glucose (all patients)

X. Imaging

  1. See Psychosis Diagnostic Testing
  2. 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]

XI. Management

  1. See Neuroleptic Medications
  2. See Schizophrenia
  3. Consider Secondary Psychosis or Delirium (due to medical conditions, organic)
    1. See Differential Diagnosis above
    2. See Unknown Ingestion
    3. See Delirium
    4. Medical clearance (or "Medically stable for psychiatric evaluation") precedes formal psychiatric evaluation
    5. Medically admit Delirium patients for acute management of underlying condition
    6. Excluding Delirium (even if only by history and exam) is critical in Acute Psychosis presentations
      1. Organic causes may account for 24-63% of psychological complaints in the Emergency Department
      2. Good (2014) West J Emerg Med 15(3):312-7 +PMID: 24868310 [PubMed]
  4. Evaluate patient safety to self and others
    1. See Emergency Mental Health Triage (includes creating a safe environment during the evaluation)
    2. Place patients on a hold if they are at a significant harm to themselves or others
    3. New onset acute Primary psychosis is typically admitted to mental health facilities
  5. Acute management of Psychosis (e.g. Schizophrenia or Mania) in the emergency department
    1. See Chemical Restraints
    2. See Sedation of the Violent Patient
    3. 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]
    4. Antipsychotic Medications
      1. Offer oral dose to patient first if cooperative and conditions allow
      2. Precautions
        1. Exercise caution in Unknown Ingestion (risk of QTc Prolongation and QRS Widening)
          1. If suspected (or stimulant ingestion), Benzodiazepines are preferred instead
      3. Olanzapine (Zyprexa)
        1. Initial
          1. Oral: 10 mg sublingual wafer and may be repeat once in 2 hours (peaks in 6 hours)
          2. IM: Give 10 mg IM or 10 mg IM and may repeat once in 20 min (peaks in 15 to 45 min)
        2. Maintenance: 10-15 mg orally daily
        3. Maximum: 20 mg/day Oral (30 mg/day IM)
      4. Risperidone
        1. Oral: Start 2 mg orally daily and may repeat once in 2 hours (peaks in 1 hour)
        2. Maximum: 6 mg/day
        3. Often preferred in elderly patients (although all Antipsychotics increase mortality risk in elderly)
      5. Haloperidol
        1. Initial
          1. Oral: 5 mg orally and may be repeated once in 15 minutes (peaks in 30-60 min)
          2. IM: 5 mg IM and may be repeated once in 15 min (peaks in 30-60 min)
          3. IV: 2 to 5 mg IV and may repeat once in 4 hours (peaks within minutes)
        2. Maximum: 20 mg/day for oral and IM (10 mg/day for IV)
      6. Ziprasidone
        1. Initial (IM dosing peaks in 15 min)
          1. Ziprasidone 10 mg IM and may repeat once in 2 hours OR
          2. Ziprasidone 20 mg IM and may repeat once in 4 hours OR
        2. Maximum: 40 mg/day
      7. Aripiprazole
        1. Initial: 9.75 mg IM and may repeat once in 2 hours (peaks in 60 min)
        2. Maximum: 30 mg/day IM
    5. Benzodiazepines
      1. Indications
        1. Alcohol Withdrawal
        2. Benzodiazepine Withdrawal
        3. CNS Stimulant Intoxication
      2. Lorazepam
        1. Initial
          1. Oral: 2 mg orally and may repeat in 2 hours (peaks in 20-30 min)
          2. IM: 2 mg IM and may repeat in 2 hours (peaks in 20-30 min)
          3. IV: 1-2 mg IV every 6 hours
        2. Maximum: 12 mg/day
    6. Other measures
      1. See Verbal Deescalation
      2. Attempt to listen to the patient (if the situation allows)
      3. Try to identify the patient's interests and find common goals
      4. Help the patient feel secure
      5. Allow the patient to make some decisions within a safe realm
    7. 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]

XII. References

  1. (2000) DSM IV, APA, p. 297-343
  2. James, Medepalli and Mehta (2025) Crit Dec Emerg Med 39(4): 4-13
  3. Freedman (2003) N Engl J Med 349:1738-49 [PubMed]
  4. Griswold (2015) Am Fam Physician 91(12):856-63 [PubMed]
  5. Schultz (2007) Am Fam Physician 75:1821-9 [PubMed]

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