Acute psychosis

Background

• Caused by many psychiatric and medical conditions
• Examples: schizophrenia, mania

Clinical Presentation

• Agitation
• Restlessness
• Irritability
• Decreased attention
• innappropriate or hostile behaviors

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

Diagnosis

• Vital signs
• Blood glucose
• signs or symptoms of intoxication or withdrawal
• signs of trauma
• rule out any organic causes or contributors

Management

• Non-pharmacologic
  • Verbal de-escalation
  • Offer comforting items: blanket, meal, pillow, etc
  • Quiet room
  • Physical restraints
    • should administer medications if restraints used (decreases restraint time)
• Pharmacologic: Goal is to calm pt 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 EPS
    • 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

Disposition

• Depends on underlying cause of psychosis
• Hospitalization for first psychotic episode, suicidal or homicidal, unable to care for self or poor support system

References

Brown, H. et al How to stabilize an acutely psychotic patient. Current Psychiatry. Dec 2012. Vol 11. No 12. p10-16
Rosen's Emergency Medicine 7th ed