Approach to psychosis

Last updated: October 11, 2022

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Psychosis is an impaired perception of reality. It may be caused by a psychiatric disorder (primary psychosis) or it may be the result of substance use, an underlying medical condition, or a mood disorder (secondary psychosis). Acute psychosis is a psychiatric emergency. The management of acute psychosis includes ensuring patient and staff safety, reducing patient agitation, ruling out a medical cause for the thought disturbance, and facilitating the appropriate disposition. Patient agitation may need to be managed before an assessment can be completed; nonpharmacological methods should be attempted first, but rapid escalation to pharmacotherapy may be necessary. Diagnostic testing is guided by the patient's history and clinical presentation. The use of broad, nondirected panels of tests is discouraged. Treatment depends on the underlying cause, but most patients require admission and psychiatry consultation.

Causes of primary psychosis

Schizophrenia spectrum disorders

The DSM-5 also considers schizotypal personality disorder to be a schizophrenia spectrum disorder (see the section on “Personality disorders” for details). [5]

Schizophrenia spectrum and other psychotic disorders [5]
Duration of symptoms Clinical features Social and occupational functioning
Schizophrenia
  • ≥ 6 months
  • Impaired
Schizophreniform disorder
  • 1–6 months
Brief psychotic disorder
  • > 1 day but ≤ 1 month
Schizoaffective disorder
  • ≥ 2 weeks of psychosis without prominent manic/depressive symptoms during the illness episode
  • Impaired
Delusional disorder
  • ≥ 1 month
  • Not markedly impaired
Other psychotic disorder: delusional symptoms in the partner of an individual with a delusional disorder
  • Not determined
  • Normal

Mood disorders and anxiety disorders

Mood-congruent delusions are usually seen in severe depression/mania, whereas schizoaffective disorder manifests with delusions that are not congruent with the mood.

Personality disorders [8]

Causes of secondary psychosis [4]

Psychotic disorder due to another medical condition

To make this diagnosis, a causal link must be established between psychosis and the underlying condition. The following medical conditions can cause psychosis:

Substance-induced psychotic disorder

To make this diagnosis, psychosis should be identified as a direct consequence of substance use or withdrawal. The following substances can induce psychosis:

Psychosis is evidenced by hallucinations, delusions, disorganized thought, and/or disorganized speech.

Hallucinations

  • Definition
    • Hallucinations: perceptual abnormalities in which sensory experiences occur in the absence of external stimuli
    • Illusions: a perceptual abnormality in which real external stimuli are misinterpreted
  • Types
    • Auditory (most common)
    • Visual
    • Somatic (tactile)
    • Gustatory
    • Olfactory

Delusions

  • Definition: fixed, false beliefs that are maintained despite being contradicted by reality or rational arguments and that are not related to one's religious beliefs or culture
  • Types
    • Bizarre delusions: delusions that cannot be true or are inconsistent with the patient's social and cultural norms (e.g., a patient insisting that they can fly)
    • Nonbizarre delusions: delusions that can be true or are consistent with the patient's social and cultural norms (e.g., a patient insisting that they have won the lottery when this is not the case)
  • Subtypes
    • Grandiosity: The patient insists that they have special powers or importance.
    • Ideas of reference: The patient believes that normal events are of special importance to them (e.g., an individual might feel that a television reporter is talking about them).
    • Paranoia: The patient has an exaggerated distrust of others and is suspicious of their motives.
    • Persecutory: The patient insists that they are being cheated on, conspired against, or harassed.
    • Erotomania: The patient believes that other individuals are in love with them.
    • Jealousy: The patient believes their partner is unfaithful without justification.
    • Somatic delusion: The patient believes they are experiencing a bodily function or sensation when there is none present.
    • Mixed delusions: two or more delusions occurring simultaneously; no delusion is predominant over the other.
    • Unspecified delusions: a delusion that does not fit the criteria of other types or that cannot be clearly defined

Disorganized thought and disorganized speech processes

Disorganized thought refers to a disturbance in the logical connection between thoughts or the flow of thoughts. Disorganized speech is a collection of speech abnormalities that lead to incoherent speech.

  • Loose associations: incoherent thinking expressed as illogical, sudden, and frequent changes of topic
  • Word salad: incoherent thinking expressed as a sequence of words without a logical connection
  • Tangential speech: nonlinear thought expressed as a gradual deviation from a focused idea or question
  • Neologisms: the creation of new words with idiosyncratic meanings
  • Echolalia: involuntary repetition of another's words or sentences
  • Flight of ideas: quick succession of thoughts usually demonstrated in a continuous flow of rapid speech and abrupt changes in topic
  • Clang association: use of words based on rhyme patterns rather than meaning
  • Circumstantial speech: nonlinear thought expressed as a long-winded manner of explanation, with multiple deviations from the central topic, before finally expressing the central idea
  • Thought-blocking: an objective observation of an abrupt ending in a thought process, expressed as a sudden interruption in speech
  • Pressured speech: accelerated thoughts that are expressed as rapid, loud, and voluminous speech, often in the absence of social stimulation

Associated clinical features

These features depend on the underlying etiology and may appear as a prodrome, concurrently with psychosis, or after psychosis has resolved.

Schizophrenia typically manifests with a prodrome of negative symptoms and psychosis (e.g., social withdrawal) that precedes the positive psychotic symptoms (e.g., hallucinations and bizarre delusions).

A medical assessment is performed in all patients with acute psychosis to differentiate between primary and secondary psychosis and to identify comorbidities that may require medical treatment. [9][10]

Initial management [3]

If there is a language or cultural barrier, use a trained interpreter with an awareness of the patient's cultural beliefs. [3]

The medical evaluation should indicate whether the patient is medically stable, include recommendations for further medical care if needed, and address whether treatment in a psychiatric facility is medically appropriate. Use of the term “medical clearance” is discouraged. [14][15]

Disposition [16]

  • Hospitalize any patient with psychosis who is a danger to themselves or others: See “Decision-making capacity and legal competence” and “Involuntary commitment.”
  • Consult psychiatry for all patients being considered for outpatient treatment.
  • Treatment in an outpatient psychiatric facility may be appropriate if:
    • The patient is not a danger to themselves or others.
    • The patient is able to attend the outpatient facility regularly.
    • A receiving facility has been identified and agrees to accept the patient.

Indications for diagnostic testing [10]

  • First episode of psychosis
  • Suspected secondary psychosis [9][10]
  • Admission to a psychiatric facility that cannot perform diagnostic testing
  • Testing as a courtesy for a receiving psychiatric facility with limited resources may be performed but should not delay the patient transfer. [9]

Agitated patients may require treatment with an antipsychotic or benzodiazepine to facilitate a diagnostic workup.

A thorough history, physical examination (including vital signs), and cognitive assessment are required for the medical evaluation of patients with psychosis. Further diagnostic studies are not routinely required but may be warranted if secondary psychosis is suspected. [9][14]

Differentiating primary from secondary psychosis

Clinical indicators for primary and secondary psychosis [4][9][10]
Indicator Primary psychosis Secondary psychosis
Age
  • Prior diagnosis of psychosis at age 12–65 years
  • Onset in patients aged 12–45 years
  • Age < 12 years or ≥ 65 years
  • Onset in patients aged > 45 years
Speed of onset
  • Gradual
  • Sudden
Physical examination
Mental status examination
  • Awake, alert
  • Oriented
  • Flat affect
  • Repetitive activity
Hallucinations
  • Auditory
Drugs
  • No new exposure
  • No recent cessation of medications

Primary psychosis due to schizophrenia is often accompanied by negative symptoms (e.g., diminished emotional expression) and/or abnormal motor behavior (e.g., catatonia). [2]

Diagnostic studies for secondary psychosis [3][17][18]

Management of agitation

For more detailed information, see “Management of the agitated or violent patient.”

Pharmacotherapy for managing agitation in acute psychosis [13]
Type of psychosis Recommended regimens
Primary psychosis
Secondary psychosis Delirium
Substance-related

Only use physical restraints if all alternatives for managing agitation have failed!

Monitoring for adverse reactions to antipsychotics

Use antipsychotics with caution in patients with prolonged QT intervals.

Definitive treatment

  1. Diagnostic and Statistical Manual of Mental Disorders.
  2. Arciniegas DB. Psychosis. CONTINUUM: Lifelong Learning in Neurology. 2015; 21 : p.715-736. doi: 10.1212/01.con.0000466662.89908.e7 . | Open in Read by QxMD
  3. Griswold KS, Del Regno PA, Berger RC. Recognition and Differential Diagnosis of Psychosis in Primary Care.. Am Fam Physician. 2015; 91 (12): p.856-63.
  4. Keshavan MS, Kaneko Y. Secondary psychoses: an update. World Psychiatry. 2013; 12 (1): p.4-15. doi: 10.1002/wps.20001 . | Open in Read by QxMD
  5. Wilson M, Nordstrom K, Anderson E, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adult Psychiatric Patients. Part II: Controversies over Medical Assessment, and Consensus Recommendations. Western Journal of Emergency Medicine. 2017; 18 (4): p.640-646. doi: 10.5811/westjem.2017.3.32259 . | Open in Read by QxMD
  6. Tucci V, Siever K, Matorin A, Moukaddam N. Down the Rabbit Hole. Emerg Med Clin North Am. 2015; 33 (4): p.721-737. doi: 10.1016/j.emc.2015.07.002 . | Open in Read by QxMD
  7. Association AP. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults, Third Edition. American Psychiatric Pub ; 2015
  8. Nazarian DJ, Broder JS, Thiessen MEW, et al. Clinical Policy: Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Ann Emerg Med. 2017; 69 (4): p.480-498. doi: 10.1016/j.annemergmed.2017.01.036 . | Open in Read by QxMD
  9. Roppolo LP, Morris DW, Khan F, et al. Improving the management of acutely agitated patients in the emergency department through implementation of Project BETA (Best Practices in the Evaluation and Treatment of Agitation). J Am Coll Emerg Physicians Open. 2020; 1 (5): p.898-907. doi: 10.1002/emp2.12138 . | Open in Read by QxMD
  10. Anderson E, Nordstrom K, Wilson M, et al. American Association for Emergency Psychiatry Task Force on Medical Clearance of Adults Part I: Introduction, Review and Evidence-Based Guidelines. Western Journal of Emergency Medicine. 2017; 18 (2): p.235-242. doi: 10.5811/westjem.2016.10.32258 . | Open in Read by QxMD
  11. Koita J, Riggio S, Jagoda A. The mental status examination in emergency practice.. Emerg Med Clin North Am. 2010; 28 (3): p.439-51. doi: 10.1016/j.emc.2010.03.008 . | Open in Read by QxMD
  12. Freudenreich O. Psychotic Disorders. Humana ; 2019
  13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. undefined. 2013 . doi: 10.1176/appi.books.9780890425596 . | Open in Read by QxMD
  14. Alberts B, Johnson A, Lewis J, Morgan D, Raff M, Roberts K, Walter P. Molecular Biology of the Cell. Garland Science ; 2014
  15. Amorim Levi GD. PTSD and Psychosis: A Review. Open Access J Addict Psychol. 2019; 2 (1). doi: 10.33552/oajap.2019.02.000527 . | Open in Read by QxMD
  16. Balaratnasingam S, Janca A. Normal personality, personality disorder and psychosis. Curr Opin Psychiatry. 2015; 28 (1): p.30-34. doi: 10.1097/yco.0000000000000124 . | Open in Read by QxMD
  17. American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. undefined. 2020 . doi: 10.1176/appi.books.9780890424841 . | Open in Read by QxMD
  18. Freudenreich O, Charles Schulz S, Goff DC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Intervention in Psychiatry. 2009; 3 (1): p.10-18. doi: 10.1111/j.1751-7893.2008.00105.x . | Open in Read by QxMD
  19. McElroy SL, Keck PE, Stanton SP, Tugrul KC, Bennett JA, Strakowski SM. A randomized comparison of divalproex oral loading versus haloperidol in the initial treatment of acute psychotic mania.. J Clin Psychiatry. 1996; 57 (4): p.142-6.
  20. Masood B, Lepping P, Romanov D, Poole R. Treatment of Alcohol-Induced Psychotic Disorder (Alcoholic Hallucinosis)—A Systematic Review. Alcohol and Alcoholism. 2017; 53 (3): p.259-267. doi: 10.1093/alcalc/agx090 . | Open in Read by QxMD
  21. Divac N, Prostran M, Jakovcevski I, Cerovac N. Second-generation antipsychotics and extrapyramidal adverse effects.. Biomed Res Int. 2014; 2014 : p.656370. doi: 10.1155/2014/656370 . | Open in Read by QxMD
  22. Drew BJ, Ackerman MJ, Funk M, et al. Prevention of Torsade de Pointes in Hospital Settings. Circulation. 2010; 121 (8): p.1047-1060. doi: 10.1161/circulationaha.109.192704 . | Open in Read by QxMD
  23. Abdelmawla N, Mitchell AJ. Sudden cardiac death and antipsychotics. Part 1: Risk factors and mechanisms. Advances in Psychiatric Treatment. 2006; 12 (1): p.35-44. doi: 10.1192/apt.12.1.35 . | Open in Read by QxMD
  24. Abdelmawla N, Mitchell AJ. Sudden cardiac death and antipsychotics Part 2: Monitoring and prevention. Advances in Psychiatric Treatment. 2006; 12 (2): p.100-109. doi: 10.1192/apt.12.2.100 . | Open in Read by QxMD
  25. Schleifer JJ. Management of acute agitation in psychosis: an evidence-based approach in the USA. Advances in Psychiatric Treatment. 2011; 17 (2): p.91-100. doi: 10.1192/apt.bp.109.007310 . | Open in Read by QxMD
  26. Stern TA, Celano CM, Gross AF, et al. The assessment and management of agitation and delirium in the general hospital.. Prim Care Companion J Clin Psychiatry. 2010; 12 (1): p.PCC.09r00938. doi: 10.4088/PCC.09r00938yel . | Open in Read by QxMD
  27. Battaglia J. Pharmacological Management of Acute Agitation. Drugs. 2005; 65 (9): p.1207-1222. doi: 10.2165/00003495-200565090-00003 . | Open in Read by QxMD

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