Acute psychosis

Background

• Loss of contact with reality characterized by hallucinations, delusions, and/or disordered thinking
• EM priority: Rule out medical (organic) causes before attributing to primary psychiatric illness
• First-episode psychosis, age >40 onset, or atypical features should always prompt thorough medical workup
• Causes: schizophrenia, bipolar disorder, substance intoxication/withdrawal, medical illness (infection, metabolic, neurologic, endocrine)

Clinical Features

• Hallucinations (auditory most common in psychiatric; visual more suggestive of organic cause)
• Delusions (paranoid, persecutory, grandiose)
• Disorganized speech or behavior
• Agitation, restlessness, irritability
• Decreased attention
• Inappropriate or hostile behaviors
• +/- additional features of underlying pathology (signs of intoxication/withdrawal, trauma, focal neurologic deficits)

Red Flags Suggesting Medical Cause

• Age >40 with no psychiatric history
• Acute onset (hours to days)
• Visual hallucinations predominant
• Altered mental status, clouding of consciousness (suggests delirium)
• Vital sign abnormalities (fever, tachycardia, hypertension)
• Focal neurologic findings
• Recent medication changes or new substances

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

• Hypoxic encephalopathy
• Acute toxic-metabolic encephalopathy (Delirium)
  • Hypoglycemia
  • Hyperosmolar state (e.g., hyperglycemia)
  • Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
  • Organ system failure
  • Hepatic Encephalopathy
  • Uremia/Renal Failure
  • Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
  • Hypoxia
  • CO2 narcosis
• Hypertensive Encephalopathy
• Toxins
• TTP / Thrombotic thrombocytopenic purpura
• Alcohol withdrawal
• Drug reactions (NMS, Serotonin Syndrome)
• Environmental causes
  • Hypothermia
  • Hyperthermia
• Deficiency state
  • Wernicke encephalopathy
  • Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
  • Vitamin D Deficiency
  • Zinc Deficiency
• Sepsis
• Osmotic demyelination syndrome (central pontine myelinolysis)
• Limbic encephalitis

Primary CNS disease or trauma

• Direct CNS trauma
  • Diffuse axonal injury
  • Subdural/epidural hematoma
• Vascular disease
  • Intraparenchymal hemorrhage
• SAH
• Stroke
  • Hemispheric, brainstem
• CNS infections
  • Encephalitis
  • Anti-NMDA receptor encephalitis
  • Meningitis
• Neoplasms
  • Paraneoplastic Limbic encephalitis
  • Malignant Meningitis
  • Pancreatic Insulinoma
• Seizures
  • Nonconvulsive status epilepticus
  • Postictal state
• Dementia
  • Alzheimer's
  • Lewy Body Dementia
  • Frontotemporal Dementia

Psychiatric

• Acute psychosis
• Catatonia
• Excited delirium
• Malingering
• Steroid induced psychosis

Psychiatric Disorders with Psychotic Symptoms

• Acute psychosis
• Schizophrenia
• Schizoaffective disorder
• Delusional disorder
• Schizotypal personality disorder
• Schizoid personality disorder
• Bipolar disorder with psychotic features

Evaluation

• Rule out organic causes before attributing to primary psychiatric illness

General ED Psychiatric Workup

• Point-of-care glucose
• CBC
• Chem 7
• LFTs
• ECG (for toxicology evaluation)
• ASA level
• Tylenol level
• Urine toxicology screen/Blood toxicology screen
• EtOH
• Urine pregnancy/beta-hCG (if female of childbearing age)
• Consider:
  • Ammonia (see Hepatic encephalopathy)
  • TSH (hypo or hyperthyroidism may mimic mental illness)
  • CXR (for Tb screen or rule-out delirium in older patient)
  • UA (for rule-out delirium in older patients)
  • Head CT (to rule-out ICH in patients with AMS)
  • Lumbar puncture (to rule-out meningitis or encephalitis)
• Consider: glucose, BMP, CBC, urine toxicology screen, TSH, urinalysis, ECG
• CT head if: first episode, focal neuro findings, altered consciousness, age >40, head trauma
• LP if meningitis/encephalitis suspected (fever + AMS)

Management

• Treat underlying condition first
• Ensure scene safety — de-escalation techniques before pharmacologic intervention

General ED Psychiatric Management

• Non-pharmacologic
  • Verbal de-escalation
  • Offer comforting items: blanket, meal, pillow, etc
  • Quiet room
  • Physical restraints (should administer medications if restraints used, as decreases restraint time)
• Pharmacologic: Goal is to calm patient without oversedation
  • No history of psychosis
    • Haloperidol 0.5mg-5mg +/- lorazepam 0.25-2mg (PO/IM/IV)
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
    • Consider risperidone 0.5-2mg PO or olanzapine 2.5-20mg (PO/IM/SL) or ziprasidone 10-20mg IM
  • Known or suspected underlying psychotic illness
    • Continue treatment with previous antipsychotic or
    • PO: olanzapine 5-10mg or risperidone 0.5-2mg +/- lorazepam: 0.5-2mg
    • IM: olanzapine 2.5-20mg or ziprasidone 10-20mg or
    • (PO/IM/IV) Haloperidol 0.5-5mg +/- lorazepam 0.5-2mg
      • Consider adding benztropine 0.5-2mg or diphenhydramine 25-50mg (PO/IV/IM) (reduces dystonia or extrapyramidal reaction)
• Pharmacologic management of acute agitation:
  • Haloperidol 5-10 mg IM + lorazepam 2 mg IM + diphenhydramine 50 mg IM (classic B52 cocktail)
  • Olanzapine 10 mg IM (avoid with benzodiazepines — risk of respiratory depression)
  • Midazolam 5 mg IM (fastest onset for severe agitation)
  • Ketamine 4-5 mg/kg IM for severe undifferentiated agitation
• Avoid restraints when possible; use least restrictive measures

Disposition

• Depends on underlying cause
• Admit/psychiatric hold: first psychotic episode, suicidal/homicidal ideation, unable to care for self, poor support system
• Discharge: known psychiatric disorder with exacerbation, medically cleared, safe disposition plan, psychiatry follow-up

See Also

• Agitated or combative patient
• Altered mental status
• Agitated delirium
• Hallucinations
• Delirium