II. Epidemiology

  1. Onset (first Psychosis episode)
    1. Males in early to mid-20s
    2. Females in late 20s

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. Types

V. Symptoms

VI. 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

VII. 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

VIII. Labs

IX. 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]

X. 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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