Psychosis

Introduction

• 0.5-1% of all ED visits and 20% of all MH presentations
• Differential
  • Psychotic disorders due to general medical condition
    • Delirium
    • Dementia
    • Psychosis in clear consciousness without cognitive impairment
    • Psychosis due to medications
  • Acute and chronic schizophrenia
  • Mania with psychosis
  • Depression with psychosis
  • Substance-induced psychosis
  • Psychotic-like reaction states

Introduction

• Schizophrenia
  • 0.2-0.5% of population with onset usually before age 30 (but anytime)
  • Variabl chronic condition
  • 20% have good recovery, 20% recurrent episodes with good recovery in between, 40% recurrent episodes with incomplete remission and 20% severe chronic course
  • 20-year suicide rate as high as 14-22%
• Bipolar disorder
  • 1% of population
  • 95% of cases onset before age 26
  • If one episode of mania, 80% chance of recurrence within 5 years
  • Usually good recovery in between but average of one episode of mania or depression each 2 years
  • 22 year suicide rate is 15%

Psychotic symptoms due to general medical condition

• Delirium
  • Usually visual illusions and delusions of persecution around healthcare
  • Auditory hallucinations, affective lability, apparent FTD and grandiose or religious delusions
  • Pathognomic features are disorientation (time and place) and fluctuating conscious state
• Dementia
  • Auditory and visual hallucinations, persecutory delusions, delusional misidentification (person closely related replaced by a double)
  • 44% of dementia patients have psychotic features
  • Need multiple cognitive deficits to diagnose dementia
  • Consider superimposed delirium if change in conscious state of dementia patient

Psychosis in clear consciousness without cognitive impairment

• Epilepsy, hypo/hyperthyroidism, Huntington’s, Wilson’s, porphyria, B12 deficiency, cerebral neoplasm, stroke, viral encephalitis, neurosyphilis, AIDS
• Consider in any new psychosis over age 40 especially
• Epilepsy
  • Chronic inter-ictal psychosis (not related to seizure activity)
    • Often presents like schizophrenia and requires antipsychotics
  • Post-ictal psychosis
    • Follows cluster of seizures sometimes with 1-2 day lucid interval in between
    • Mental state returns to normal within days and does not require chronic antipsychotic therapy 
    • Managed with seizure prophylaxis

Psychosis due to medications

• Steroids are classic
• Dopamine agonists can cause auditory/visual hallucinations, persecutory delusions and hypomania

Acute and chronic schizophrenia

• Positive symptoms
  • Delusion, hallucinations and formal thought disorder
  • Often grandiose delusions, religiose communications or hypochondriacal/nihilistic delusions
  • Delusions of reference through media
  • Delusions of persecution
  • Usually auditory hallucinations
    • Running commentary, two or more voices arguing about patient and voice repeating patient’s thoughts aloud

Acute and chronic schizophrenia

• Negative symptoms
  • Blunted affect
  • Apathy
  • Poverty of speech
  • Autistic withdrawal from social interaction
  • Can be difficult to distinguish from depression or bradykinesia secondary to antipsychotics

Acute and chronic schizophrenia

• First psychotic episode
  • Typically months of deterioration and then crisis brings to a head
  • Must exclude medical causes, especially if over 40
• Acute psychotic relapse
  • Look for precipitants, drugs and stressful events
• Social crisis in chronic schizophrenia
  • Often helpful to communicate with community care providers re: baseline function and current problems
  • Social input is crucial + compliance with medications

Mania with psychotic symptoms

• Euphoric, irritable, pressured speech, distractible and disinhibited
• Often grandiose or persecutory delusions (conspiracy to prevent realising potential)
• Markedly decreased need for sleep

Major depression with psychotic features

• If psychotic features evident in depressive episode = severe
• Often delusion and hallucinations revolve around low self-esteem and guilt
• Unable to evaluate beliefs rationally and suicide risk is high

Substance-induced psychosis

• Can be due to acute intoxication, withdrawal reactions, chronic psychosis following prolonged use and exacerbation of pre-existing psychotic illness due to drug abuse
• Drugs
  • Meth, MDMA, cocaine, phencyclidine, LSD, ketamine, cannabis, alcohol and benzodiazepines
• Usually autonomic signs and agitation

Substance-induced psychosis

• Phencyclidine particularly associated with disinhibited rage
• Amphetamines, phencyclidine and LSD all associated with psychosis that can persist for weeks or months after cessation
  • Has to be treated in its own right
• Alcoholic hallucinosis can be seen in chronic alcoholism with running commentary (often derogatory) despite clear consciousness, without being in a withdrawal state

Psychotic-like reactive states

• Severe personality disorder, PTSD and dissociative disorder can all present with quasi-psychotic states
• Usually following acute stress in crisis

Last Updated on October 7, 2020 by Andrew Crofton