Acute Psychosis

Introduction & Etiology - Psychosis Unveiled

• Psychosis: Acute syndrome; loss of reality contact. Manifests as hallucinations (esp. auditory), delusions, disorganized thought/speech/behavior. A psychiatric emergency.
• Etiology (Triad):
  • Primary Psychiatric: Schizophrenia, Bipolar I (mania), Brief Psychotic Disorder.
  • Substance-Induced: Alcohol (withdrawal), Cannabis, Stimulants (e.g., amphetamine).
  • Organic/Medical (Secondary):
    • CNS: Infections (encephalitis), trauma, tumor, epilepsy.
    • Metabolic: Hypoglycemia, uremia, hepatic encephalopathy.
    • Endocrine: Thyroid storm, Cushing's.
    • Autoimmune: Anti-NMDA Receptor Encephalitis.

    ⭐ Delirium can mimic psychosis; always rule out organic causes first in new-onset psychosis, especially in elderly or medically ill.

• Pathophysiology: Primarily ↑ dopamine in mesolimbic pathway. oka

Clinical Features - Mind in Turmoil

• Perception: Hallucinations (auditory most common; e.g., voices commenting, commanding).
• Thought Content: Delusions (fixed, false beliefs; e.g., persecutory, grandiose, referential).
• Thought Form/Stream: Disorganized speech (e.g., flight of ideas, tangentiality, incoherence, thought block).
• Behavior: Agitation, aggression, unpredictable actions, bizarre posturing, catatonic features (stupor, excitement), poor self-care.
• Mood & Affect: Incongruent affect, labile mood, perplexity, fear, irritability.
• Insight & Judgment: Markedly impaired insight (unawareness of illness); poor judgment leading to risk.

⭐ Auditory hallucinations, especially third-person (voices discussing patient) or thought echo, are highly suggestive of schizophrenia-spectrum psychosis but can occur in other psychoses too.

Differential Diagnosis - Spotting the Mimics

Acute psychosis requires rapid exclusion of organic causes.

• 📌 Key Red Flags for Organic Cause:
  • Sudden onset, age >40
  • Fluctuating sensorium (delirium)
  • Abnormal vitals, neuro deficits
  • Substance use, new meds
  • No prior psych history

⭐ New-onset psychosis in older adults or with atypical features (visual hallucinations, cognitive issues) strongly suggests an organic cause.

Investigations - Unmasking the Truth

• Goals: Rule out organic causes, establish baseline.
• Core Bloods & Urine:
  • CBC, inflammatory markers (ESR, CRP)
  • RFT, LFT, electrolytes, glucose
  • TFTs
  • Urine R/M, Urine Drug Screen (UDS)
• Essential: ECG (baseline QTc).
• Neuroimaging (CT/MRI): If:
  • First episode psychosis
  • Focal neurological deficits
  • Head trauma, atypical course
• Targeted (if suspected):
  • EEG (seizures)
  • LP (CNS infection)
  • Serology (HIV, VDRL), Vit B12/Folate

⭐ Neuroimaging (CT/MRI) is crucial in first-episode psychosis to exclude structural brain pathology.

Emergency Management - Calming the Storm

• Safety First: Ensure safety (patient, staff). Verbal de-escalation. Low-stimulus environment.
• Medical Assessment: Rule out organic causes (📌 DIMS: Drugs, Infection, Metabolic, Structural). Check vitals, glucose, O2 sat. Labs: electrolytes, tox screen. Consider ECG, CT head.
• Rapid Tranquilization (RT): If de-escalation fails/danger.
  • Oral (cooperative): Risperidone 1-2mg / Olanzapine 5-10mg.
  • IM (agitation): Lorazepam 2-4mg; Haloperidol 5mg; Olanzapine 5-10mg.
  • Combination (e.g., Haloperidol 5mg + Lorazepam 2mg IM) effective.
• Physical Restraints: Last resort for safety. Monitor closely. Document.

⭐ Always prioritize excluding reversible medical/toxic causes of psychosis before initiating antipsychotics if the clinical picture is unclear.

High‑Yield Points - ⚡ Biggest Takeaways

• Always rule out organic causes (delirium, substances, medical illness) first in acute psychosis.
• Patient and staff safety is paramount; use rapid tranquilization (e.g., haloperidol, olanzapine) for severe agitation.
• Distinguish from delirium: psychosis has clear sensorium, delirium has fluctuating consciousness.
• Schneiderian first-rank symptoms strongly suggest schizophrenia but are not pathognomonic.
• Monitor for antipsychotic side effects: acute dystonia, akathisia, NMS.
• Duration is key: Brief Psychotic Disorder (<1 month), Schizophreniform (1‑6 months).