Psychosis
Scott Zeller
Joshua Niclas
Acute psychosis, although one of the most common presenting problems in emergency psychiatry, can be a very difficult diagnostic and therapeutic challenge (1). In addition to exacerbations of severe mental illnesses such as schizophrenia and bipolar disorder, medical and substance-induced conditions can present with symptoms of psychosis. Because many of the nonpsychiatric causes of psychosis can be life threatening, the correct diagnosis of the origin of psychotic symptoms is one of the most important skills to develop for those practicing psychiatry in acute settings.
PRESENTING CLINICAL FEATURES
The predominant symptoms of acute psychoses include hallucinations, delusions and ideas of reference, and disorganized thought processes and behaviors. Other features of psychotic illnesses that might lead to an emergency presentation include catatonia and prominent negative symptoms.
Hallucinations
Patients with psychotic illnesses commonly complain of auditory hallucinations, sometimes referred to as “hearing voices.” Often the auditory hallucination will be a person’s voice or several voices. Some patients describe the voices as an innocuous running commentary on daily activities, whereas other voices can be derogatory, threatening, or commanding. The latter are of the most concern in the emergency setting, because these hallucinations might induce dangerous behaviors toward self or others. A patient hearing a derogatory voice saying he is worthless might feel like killing himself. A patient hearing a hallucination telling her to strike a family member might act on the command.
Nonauditory hallucinations, such as tactile, olfactory, or visual, rarely occur in endogenous psychiatric disorders such as schizophrenia. The presence of these types of hallucinations should lead clinicians to investigate organic causes, especially toxic or withdrawal states.
Delusions and Ideas of Reference
Delusions, especially paranoid delusions, are frequently seen in psychotic illnesses. Many of the subtypes of delusions can lead to a presentation to the psychiatric emergency service (PES), sometimes with imminent danger. Paranoid delusions may lead patients to flee, hide, or strike out against the supposed persecutor. Ideas of reference include when patients believe that television programs or newspaper stories are about them or are sending them secret messages, as well as the belief that surrounding objects and events are contrived only for the patient. Ideas of reference may lead patients to damage persons or property that they believe are referring to them.
For example, a person who believes that a television anchor’s routine stories are really about the patient may destroy all the televisions in the house. Nihilistic delusions may result in a patient refusing to eat, because he or she is “already dead.” Persons with somatic delusions may become very functionally impaired from a belief that their body is giving off a toxic odor or that they are infected with “bugs.” Erotomanic delusions may lead to stalking behaviors and inability to obey restraining orders, leading to arrest.
A good history and collateral investigation are important in evaluating delusions. What might seem delusional at first glance may indeed be a true cause of concern. Many an emergency psychiatry veteran can share experiences such as a patient, apparently delusional that the Secret
Service was after him, who was shown to be otherwise minutes later—when a federal agent arrived seeking the patient for threats against the president.
Service was after him, who was shown to be otherwise minutes later—when a federal agent arrived seeking the patient for threats against the president.
Disorganized Thought Processes and Behaviors
Psychotic disorganization in a patient can lead to an emergency presentation when confusion becomes so prevalent that a person cannot adequately care for himself, or such behaviors endanger the patient. This might manifest itself in someone who wanders the streets, not knowing where home is; a person who turns on dangerous appliances or gas burners without realizing it; or a person who eats rotting food from garbage dumpsters and drinks sewer water. Disorganization may be revealed in a person whose speech is rambling, confused, or circumstantial, leading to difficulty with conversations or making simple requests.
Catatonia
The term catatonia refers to a cluster of symptoms that can include mutism, negativism, grimac-ing, posturing, catalepsy, and apparent stupor. A patient in a catatonic state may display minimal spontaneous speech, lack of response to outside stimuli, purposeless resistance to commands, odd facial expressions or body positions, resistance to attempts by others to move the patient’s limbs, or minimal spontaneous movement. A patient with catatonia may present to the PES because of extremes of behavior, total lack of behavior, or violent activity associated with catatonia. The condition can rapidly evolve into a medical crisis due to inadequate oral intake and rhabdomyolysis induced by muscle contraction or increased psychomotor activity.
Negative and Cognitive Symptoms
Negative and cognitive symptoms are common in the psychotic illnesses. These include memory impairment, difficulty with decision making, social isolation, lack of initiative, lack of social connectivity, and little or no spontaneous speech. Referrals to the PES will usually come from concerned family or friends, dismayed by the patient’s change in affect and cognition. The acuity upon presentation rarely rises to the level of an emergency.
IMMEDIATE INTERVENTIONS FOR ACUTE PRESENTATIONS
The acutely psychotic patient needs to be immediately assessed for medical instability, and should receive medical care or treatment promptly when indicated. Especially in the case of a highly paranoid or hallucinating individual, safety should be at the forefront; a calm, quiet observation room might be appropriate. Because neuroleptic medications do not have an immediate antipsychotic effect, there is little reason for their use solely for psychosis prior to a thorough evaluation. However, clinicians may wish to use emergency antiagitation or antianxiety medication to help calm the patient for the assessment.
ASSESSMENT
When a patient presents with a presumptive psy-chosis, the most important first step is an assessment of the individual, which should precede any interventions short of ensuring safety. This is because many medical, organic, and toxic etiologies—some of which are life threatening—can mimic the symptoms of an acute psychosis.
A visual assessment, or “eyeball,” of the patient should be the first step and can be done even when a patient is on a gurney or in the custody of police officers. Does the patient have markedly dilated pupils? Is the patient thrashing about, sweating profusely, or flushed? Readily observable signs such as these can be key indicators of the cause of current symptoms. If the patient can cooperate, a targeted review of systems should be completed. PES personnel should look early on for easily recognized symptoms of delirium.
Next, it is essential to gather a quick and relevant initial history. Why is the patient here? What is the key presenting problem? Has there been any recent ingestion or substance abuse? While this is being ascertained, the taking of vital signs can commence. Fever, tachycardia, and elevated blood pressure can all indicate a medical cause for the current symptoms. Acute conditions that warrant an immediate transfer to an emergency medical facility are listed in Table 16.1.
TABLE 16.1 Conditions Warranting Transfer to a Medical Emergency Department | ||||||||
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Safety Interventions
Once obvious emergency medical conditions are ruled out, if a patient’s psychosis is leading to the potential for self-harm or harm to others, ensuring safety is a fundamental next step. This will allow for further evaluation in an environment that minimizes risk.
Safety options can include heightened supervision, one-to-one observation by staff, isolation to a quiet room with reduced stimuli, and, least desirably, seclusion, restraint, and forced medications.
EVALUATION
A thorough evaluation and history are essential for all presenting cases of acute psychosis. Even if a patient is familiar to emergency staff, it should not be assumed that the current presentation is a repeat of previous episodes. Even a recidivist patient with frequent previous episodes of psychosis might have the current presentation caused by a different etiology.
Nursing Evaluation
Nursing staff should do a proper triage evaluation, as described in Chapter 3. This should always include vital signs and a nursing physical history and exam where appropriate. If possible, pulse oximetry, Breathalyzer, urine drug screens, and fingerstick glucose testing can be of great value.
Physician Evaluation
Medical staff should obtain as complete a history as possible given the patient’s current mental status. With an acutely psychotic individual, it is important for PES clinicians to be calm while being brief and direct with questions. Disturbing, challenging, or arguing with the psychotic patient should be avoided.
A careful mental status examination is a must prior to making any treatment decisions. At this point, a more careful assessment for delirium should be completed, with special attention being paid to the level of consciousness, orientation, and presence of waxing and waning features. Key to the mental status exam is inquiry about the symptoms of psychosis and whether the content and affect associated with the psychosis increase the potential for harmful behaviors.
A hands-on physical examination by the psychiatrist is usually not recommended unless there is clear evidence of an acute physical abnormality and no nonpsychiatric physician is present. Patients may have exacerbations of paranoia induced by the psychiatrist touching or invading their personal space. More delusional or sexually preoccupied patients might assign sexual intent to such an evaluation. Most physical determinations of the etiology of psychosis can be ascertained by visual clues or a thorough history.
Collateral Information
Obtaining as much collateral information about the patient as possible in the time available is essential. Significant others, roommates, board and care facility operators, case managers, and outpatient physicians are good sources for collateral data. Any past medical or psychiatric records are helpful, especially in regard to the effectiveness and tolerability of previous medication. PES clinicians should be aware that they must work quickly regardless of the ability to obtain collateral information or medical records, and should not wait for either prior to beginning an assessment.
Laboratory Tests
If feasible, obtain a fingerstick glucose level, urine or serum toxicology, and pregnancy screen as soon as possible. Other key labs might be electrolytes (to check for metabolic abnormalities), complete blood count (CBC) and urinalysis (to rule out infectious states), and thyroid-stimulating hormone level (to rule out thyroid abnormalities). If there is an indication that the patient is on lithium, valproate, or other medications requiring monitoring, obtaining levels of these will help exclude toxic delirium states or noncompliance.
DIFFERENTIAL DIAGNOSIS
Nonpsychiatric Causes
A great many organic, toxic, and medical disorders may present with symptoms of acute psychosis (2). As many as 20% of episodes of psychosis presenting to a medical emergency department may be caused by medical reasons (3). The following syndromes, although constituting some of the most common nonpsychiatric causes, certainly do not represent all possibilities. It is very important for clinicians to always consider all of a patient’s medical history and any ingested substances, including medication, food, and herbal supplements.
SUBSTANCE-INDUCED
Amphetamines
Amphetamines stimulate dopaminergic pathways in the brain. Ingestion, smoking, or intravenous injection of amphetamines can lead to psychotic symptoms that mimic positive symptoms of schizophrenia. One study showed that methamphetamine abusers are 11 times more likely than the general population to experience symptoms of psychosis (4). These can include auditory hallucinations and paranoid delusions (e.g., someone peeking at them through a window, audiotaping or videotaping them, following them, or trying to harm them). In addition, some patients intoxicated on amphetamines will have tactile hallucinations, often feeling they are covered with bugs (formication). This sensation will often lead to injurious self-picking behavior. Additional behaviors may include agitation, aggression, hyperkinesis, and repetitive, stereotyped body movements. Elevated blood pressure and tachycardia may be present. Amphetamine-induced psychosis usually resolves within 24 to 48 hours as the drug detoxifies from the body.
3,4-Methylenedioxymethamphetamine (MDMA)
MDMA, also known as Ecstasy, is a popular substance of abuse at all-night dance parties known as raves. Although MDMA, like methamphetamine, stimulates dopaminergic pathways, it has much higher serotonergic effects, leading to its combination of stimulant and hallucinogenic properties. It can produce unpleasant psychotic phenomena, including paranoia, auditory and visual hallucinations, and delusions. In addition, depersonalization, derealization, and depression are common (5,6,7). Conversely, abusers of this drug often state that it induces feelings of love, empathy, and emotional closeness toward others.
Cocaine
Another dopaminergic agonist, cocaine, can be snorted, smoked, or injected. Studies of the effects of cocaine intoxication have found that 17% to 53% of patients under the influence of this drug experience psychotic symptoms (8,9,10). Patients abusing this substance can present with auditory hallucinations, tactile hallucinations including formication, and paranoid delusions. As with amphetamines, cocaine can also cause hyperkinetic, repetitive, and stereotyped behaviors as well as aggression and agitation. Elevated blood pressure and tachycardia may be present. Cocaine- induced psychosis usually resolves within 24 hours as the drug detoxifies from the body.
Phencyclidine
The NMDA receptor antagonist phencyclidine (PCP) can cause symptoms that mimic both positive and negative symptoms of schizophrenia. This substance is usually smoked. Intoxicated patients have a high risk for experiencing hallucinations and paranoid delusions, in addition to displaying agitated, bizarre, or catatonic behavior. A study that examined clinical patterns of acute PCP intoxication found a state of toxic psychosis in 16.6% of its intoxicated subjects (11). Patients may exhibit hypertension, tachycardia, horizontal and vertical nystagmus, ataxia, increased muscle tone, tremors,
brisk deep tendon reflexes, diaphoresis, lacrimation, and increased salivary secretions. Decreased sensation may also be present and is sometimes associated with violent behavior regardless of self-induced injury.
brisk deep tendon reflexes, diaphoresis, lacrimation, and increased salivary secretions. Decreased sensation may also be present and is sometimes associated with violent behavior regardless of self-induced injury.
Hallucinogens
LSD, mescaline, and psilocybin cause perceptual disturbances that can include intensification of cognitive perceptions, depersonalization, derealization, illusions, hallucination, palinopsia, and synesthesias. Hallucinations are usually visual and not auditory or tactile.
Anticholinergics
Anticholinergic intoxication can result in delirium, agitation, and visual hallucinations. A physical exam may reveal dilated pupils; warm, dry skin; dry mouth; tachycardia; hypertension; and urinary retention. Constipation caused by anticholinergic medications may result in impaction with severe agitation and aggression in the el-derly. Anticholinergic substances include both medications (e.g., benztropine, atropine) and botanicals (e.g., Atropa belladonna and Datura stramonium, or jimson weed).
Anabolic Steroids
Steroids are abused by athletes and bodybuilders to enhance physical strength and muscle mass. It is not uncommon for amounts used to be one to two orders of magnitude greater than that needed to achieve therapeutic levels. Also, different anabolic steroids may be used simultaneously. A study of athletes and bodybuilders using anabolic steroids found that 12% displayed psychotic symptoms (12). Studies also suggest that abuse of these agents may lead to violent and homicidal behavior (13).
Other Sources
A great many substances have the potential for creating symptoms of psychosis when abused. Inhaling glues, paints, or fuels (“huffing”), especially in chronic abusers, can cause profound hallucinations, cognitive impairment, and paranoia (14). The seemingly innocuous spice nutmeg can be abused for hallucinatory effects and was at one time a popular contraband in prisons (15). Many legitimately prescribed and over-the-counter med- ications can induce psychosis when taken excessively or at therapeutic doses. Examples are digoxin, isoniazid, some vitamins, and herbal remedies (16,17). When doing a psychosis evaluation in the PES, patients must be asked about every substance they have been consuming.
WITHDRAWAL STATES
Alcohol Withdrawal
A patient with a history of alcohol dependence is at risk for alcohol withdrawal after cessation or reduction in consumption of alcohol. In addition to tremulousness, diaphoresis, hypertension, tachycardia, orthostatic hypotension, seizures, irritability, anxiety, depression, and insomnia, such a patient can also experience hallucinations. If the alcohol withdrawal is severe enough, the patient may suffer from delirium tremens. This syndrome usually begins 2 to 4 days after heavy drinking has stopped. In this case, the patient may experience auditory (e.g., persecutory, threatening, derogatory), visual (e.g., snakes, rodents), and tactile hallucinations, delusions, confusion, agitation, and autonomic instability (18). Alcohol withdrawal can be a life-threatening emergency.
Benzodiazepine Withdrawal
In similar fashion to alcohol withdrawal, patients with a history of chronic benzodiazepine use can undergo a withdrawal syndrome. The withdrawal syndrome can become severe enough that a life-threatening delirium occurs, characterized by auditory, visual, or tactile hallucinations. Additional symptoms include tachycardia, hypertension, nausea, vomiting, tremor, insomnia, anxiety, and agitation. There is a significant risk for seizures, particularly with short-acting benzodiazepines.
Opioid Withdrawal
Persons in acute opiate withdrawal frequently present to emergency settings. They may claim hallucinations or other psychotic symptoms, but these are unlikely in pure opiate withdrawal and should be viewed with skepticism. Drug-seeking behavior needs to be ruled out.
METABOLIC ABNORMALITIES
Hypoglycemia or Hyperglycemia
Low serum blood glucose levels can present with psychosis in the context of confusion, agitation, aggression, fatigue, headache, impaired cognitive
functioning, seizures, and loss of consciousness (19,20). In addition, hyperglycemic patients in early diabetic ketoacidosis may present with psychosis and delirium.
functioning, seizures, and loss of consciousness (19,20). In addition, hyperglycemic patients in early diabetic ketoacidosis may present with psychosis and delirium.
Hypothyroidism or Hyperthyroidism
Hypofunction or hyperfunction of the thyroid can result in florid psychosis. In the hypothyroid state, both auditory hallucinations and paranoia (myxedema madness) can occur in the context of the physical symptoms related to metabolic slowing (21). In severe cases of hyperthyroidism (thyrotoxicosis), a patient may have psychotic symptoms such as hallucinations and paranoid delusions, as well as symptoms of depression or mania (22).
Hypocalcemia or Hypercalcemia and Parathyroid States
Hypocalcemia can present with mental status changes including psychosis, irritability, and depression. Carpopedal and laryngeal muscle spasms may be present, along with facial grimacing and convulsions. Hypercalcemia can lead to fatigue, depression, and mental confusion. Hypo-parathyroidism, a cause of abnormally low serum calcium levels, causes psychiatric disturbances including psychosis (23
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