Urgent considerations
See Differentials for more details
Acute psychosis
Acute psychosis is a rapid worsening in psychotic symptoms, including severe delusions or hallucinatory experiences, that may result in psychomotor agitation and aggression.[51] Psychosis-induced agitation and aggression are psychiatric emergencies where fast‐acting interventions are required. Oral or intramuscular benzodiazepines and/or antipsychotics, either given alone or in combination, are used for urgent pharmacological tranquillisation or sedation.
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Safety
In the US, schizophrenia is the second most frequent diagnosis for mental health-related hospitalisations.[52] People with psychosis may experience command auditory hallucinations directing them to harm themselves or others, coupled with poor insight and impaired judgement. Hospitalisation is recommended if the patient feels compelled to act, or their judgement is impaired to a level where they cannot contract for safety. In addition to psychotic symptoms, people with psychotic disorders have an increased risk for suicidality.[53] About 20% of people with schizophrenia attempt suicide, and about 10% die by suicide.[54]
Psychosis can present with severe thought disorder, poor judgement, and poor insight, which together with other psychotic symptoms can greatly impair an individual’s ability to function, including their ability to secure shelter or food. Danger to self or others, or grave functional impairment, are common reasons for hospitalisation for people with psychosis.
Involuntary admission to hospital
Involuntary hospitalisation criteria are specific to the state/country that the physician is working in. In general, it is required when patients present an imminent danger to themselves or others. This may be due to disorganisation and inability to care for themselves, aggression, unpredictability due to severe delusions or hallucinations (in particular, command hallucinations), bizarre behaviour, or depression with suicidality or homicidality. Patients who are involuntarily committed to hospital may require urgent forced medication.
Delirium
Delirium is an acute confusional state associated with increased morbidity and mortality. It is a medical emergency, occurring most often in older and medically ill patients. It should be suspected if there is any acute or subacute deterioration in behaviour, cognition, or function. Almost any illness, intoxication, or medication can cause delirium, and at least two contributing aetiologies are often present.
A complete assessment of mental status is required to make the diagnosis. The presence of a fluctuating level of consciousness is a feature of delirium that distinguishes it from psychosis. Large fluctuations in symptoms may occur from hour to hour. Delirious patients are disorientated and have poor attention and memory. A careful history, physical examination, and laboratory and radiographic studies are required to identify the underlying cause(s), such as:
Drug interactions
Drug intoxication or withdrawal
Hyper- or hypothermia
Hypo- or hyperglycaemia
Hypoxia
Infections
"Intensive care unit psychosis"
Metabolic abnormalities
Postoperative or postictal states
Sleep disturbance
Space-occupying lesions of the brain
Traumatic brain injury.
Treatment is targeted at the underlying cause(s). Safety of the patient is critical; constant observation is required. National guidance should be followed. Physical restraints should not be routinely used but may be required in an agitated delirious patient who is pulling out necessary medical devices or is combative with staff.
UK quality of care guidelines recommend that antipsychotic medication should only be considered as a short-term option for delirium, and only if the patient is distressed or a risk to themselves or others and when other non-pharmacological management techniques are unsuccessful or inappropriate.[55]
Traumatic brain injury
A subdural haematoma following recent head trauma may present with psychosis. Features include a history of a fall or head trauma; a magnetic resonance imaging (MRI) or enhanced computed tomography (CT) scan of the brain will confirm the diagnosis. Treatment of subdural haematoma is usually surgical.
The risk of psychosis increases after a concussion.
Central nervous system (CNS) infections
CNS infections often present with delirium, but psychosis may rarely be a prominent feature. Work-up includes a full blood count, blood serology for specific viruses, cerebrospinal fluid analysis and serology, EEG (specific changes can be observed in some types of viral encephalitis) and an MRI scan of the brain (specific changes can be observed in some types of viral encephalitis) may show an abnormality pattern specific to the infectious agent. Once the diagnosis has been determined, treatment of the underlying infection should be started.
Intracranial tumours
Seizures, headaches, and focal neurological deficits, such as leg or arm weakness or loss of vision, are common initial symptoms of brain tumours. Psychosis is a rare symptom. Focal neurological examination findings depend on the location of the tumour. Generalised features, including an altered level of consciousness, and personality change may also occur. MRI or enhanced CT scan of the brain aids diagnosis. A chest x-ray should also be considered if there is any suspicion of brain metastases. Cancers most likely to metastasise to the brain include lung, breast, skin, kidney, and those originating in the gastrointestinal tract. See the BMJ Best Practice topic “Overview of brain tumours”.
Organophosphate poisoning
Organophosphates are a large group of chemicals that are used in both domestic and industrial settings. Examples include insecticides, herbicides, nerve gases, and ophthalmic agents. The symptoms of toxicity sometimes include psychosis. The consensus is that neuropsychiatric symptoms occur only if toxicity is great enough to cause acute cholinergic symptoms.[56]
The clinical signs and symptoms vary depending on the specific chemical, the route, and the amount of exposure. There is often an initial acute cholinergic crisis and an intermediate phase of respiratory paralysis (24 to 96 hours), which is followed at 1 to 3 weeks by neuropathy. Physical symptoms and signs include bronchospasm, nausea and vomiting, blurred vision, diaphoresis, confusion, anxiety, respiratory paralysis, and extrapyramidal symptoms. The cardiovascular status of the patient varies. The patient can have hypotension or hypertension, and bradycardia or tachycardia.
Management of patients involves early expert help and critical care input. See the BMJ Best Practice topic “Organophosphate poisoning”.
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