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Emergency And Acute Medicine – Acute Psychosis
Acute psychosis is a disorder of brain function characterized by loss of contact with reality, abnormal perceptions, and disorganization of thought, emotion, and behavior. Dopaminergic pathways are strongly implicated in its pathophysiology. Psychosis may arise from primary psychiatric disorders or from medical, neurologic, metabolic, infectious, toxicologic, or pharmacologic causes. Because many medical conditions can mimic or precipitate psychosis, evaluation in the emergency setting must remain broad.
Medical and nonpsychiatric causes include neurologic disorders such as head injury, dementia, stroke, seizures, brain tumors, hydrocephalus, demyelinating disease, and neurodegenerative conditions. Infections such as urinary tract infection, pneumonia, HIV, neurosyphilis, Lyme disease, meningitis, encephalitis, and fungal infections may precipitate psychosis. Metabolic disturbances—including electrolyte imbalance, hypoglycemia, hypoxia, hypercarbia, porphyria, and organ failure (hepatic, renal, or cardiac)—must be considered. Endocrine abnormalities (thyroid, parathyroid, adrenal disorders), nutritional deficiencies (thiamine, niacin, B12, folate), autoimmune conditions, and paraneoplastic syndromes are also implicated. Numerous medications, including steroids, anticholinergics, dopaminergic agents, antibiotics, antivirals, chemotherapeutics, and sedative–hypnotics, may cause psychosis. Intoxication or withdrawal from alcohol, stimulants, opioids, hallucinogens, cannabis, benzodiazepines, or other substances is common. Primary psychiatric causes include brief psychotic disorder, schizophrenia spectrum disorders, mood disorders with psychotic features, schizoaffective disorder, and postpartum psychosis.
Core features of psychosis include delusions—fixed false beliefs not amenable to logic—often persecutory, religious, or somatic in nature. Hallucinations are sensory perceptions without external stimuli, most commonly auditory or visual. Thought disorder may manifest as loose associations, tangentiality, neologisms, or word salad. Disorganized or catatonic behavior may be present. Negative symptoms include flat affect, apathy, anhedonia, and social withdrawal. Features suggesting a medical rather than primary psychiatric etiology include sudden onset in patients over age 30, fluctuating course, abnormal vital signs, focal neurologic deficits, altered orientation or attention, and prominent visual, olfactory, gustatory, or tactile hallucinations.
History should assess onset, duration, triggers, and symptom content, including suicidal or homicidal ideation. Inquiry into recent medication changes, substance use or withdrawal, past psychiatric and medical history, and ability to care for self is essential. Collateral information from family or caregivers is often invaluable. Physical examination must include vital signs, general medical assessment, focused neurologic and cognitive evaluation, and careful screening for delirium.
The workup is guided by clinical suspicion. Basic laboratory studies often include electrolytes, renal function, glucose, calcium, CBC, thyroid-stimulating hormone, and toxicology screening. Urinalysis may identify infection. Further studies are tailored to suspected etiologies. Neuroimaging should be considered in new-onset psychosis of unclear cause, especially when focal neurologic findings are present. Lumbar puncture, EEG, or ECG (for QT monitoring) may be indicated depending on presentation.
Management prioritizes safety of the patient and staff. A calm environment, verbal de-escalation, removal of dangerous objects, and constant observation are first-line interventions. If agitation persists or safety is compromised, pharmacologic or physical restraints may be necessary. When a medical cause is suspected, the underlying condition must be identified and treated. If a primary psychiatric etiology is likely, psychiatric consultation should be obtained.
Antipsychotic medications are first-line for acute agitation associated with psychosis. Haloperidol 2–10 mg PO/IM/IV may be repeated as needed and is often combined with lorazepam for rapid tranquilization. Second-generation antipsychotics such as olanzapine, risperidone, aripiprazole, quetiapine, chlorpromazine, or ziprasidone may be used depending on clinical context. Ziprasidone requires QT monitoring. Concurrent use of IM olanzapine with IV benzodiazepines should be avoided due to risk of cardiopulmonary collapse. Benzodiazepines such as lorazepam 1–2 mg PO/IM/IV may augment sedation. Clinicians must monitor for extrapyramidal symptoms and neuroleptic malignant syndrome, characterized by hyperthermia, rigidity, autonomic instability, and altered mental status. Elderly patients with dementia-related psychosis have increased mortality risk when treated with antipsychotics.
Disposition depends on etiology and risk assessment. Patients with medical causes require admission to an appropriate medical service. Patients with psychiatric causes may require psychiatric hospitalization if they are a danger to themselves or others, are gravely disabled, or have new-onset psychosis after medical causes are excluded. Discharge may be appropriate if symptoms resolve, the patient is medically stable, not dangerous, and able to care for themselves, with prompt outpatient psychiatric follow-up arranged.
Psychosis should never be presumed to be purely psychiatric without appropriate evaluation for reversible medical causes, even in patients with known psychiatric illness. Visual or multisensory hallucinations, fluctuating mental status, or abnormal vital signs warrant thorough medical assessment. Early identification and treatment of reversible causes can significantly improve outcomes.
Acute psychosis is a disorder of brain function characterized by loss of contact with reality, abnormal perceptions, and disorganization of thought, emotion, and behavior. Dopaminergic pathways are strongly implicated in its pathophysiology. Psychosis may arise from primary psychiatric disorders or from medical, neurologic, metabolic, infectious, toxicologic, or pharmacologic causes. Because many medical conditions can mimic or precipitate psychosis, evaluation in the emergency setting must remain broad.
Medical and nonpsychiatric causes include neurologic disorders such as head injury, dementia, stroke, seizures, brain tumors, hydrocephalus, demyelinating disease, and neurodegenerative conditions. Infections such as urinary tract infection, pneumonia, HIV, neurosyphilis, Lyme disease, meningitis, encephalitis, and fungal infections may precipitate psychosis. Metabolic disturbances—including electrolyte imbalance, hypoglycemia, hypoxia, hypercarbia, porphyria, and organ failure (hepatic, renal, or cardiac)—must be considered. Endocrine abnormalities (thyroid, parathyroid, adrenal disorders), nutritional deficiencies (thiamine, niacin, B12, folate), autoimmune conditions, and paraneoplastic syndromes are also implicated. Numerous medications, including steroids, anticholinergics, dopaminergic agents, antibiotics, antivirals, chemotherapeutics, and sedative–hypnotics, may cause psychosis. Intoxication or withdrawal from alcohol, stimulants, opioids, hallucinogens, cannabis, benzodiazepines, or other substances is common. Primary psychiatric causes include brief psychotic disorder, schizophrenia spectrum disorders, mood disorders with psychotic features, schizoaffective disorder, and postpartum psychosis.
Core features of psychosis include delusions—fixed false beliefs not amenable to logic—often persecutory, religious, or somatic in nature. Hallucinations are sensory perceptions without external stimuli, most commonly auditory or visual. Thought disorder may manifest as loose associations, tangentiality, neologisms, or word salad. Disorganized or catatonic behavior may be present. Negative symptoms include flat affect, apathy, anhedonia, and social withdrawal. Features suggesting a medical rather than primary psychiatric etiology include sudden onset in patients over age 30, fluctuating course, abnormal vital signs, focal neurologic deficits, altered orientation or attention, and prominent visual, olfactory, gustatory, or tactile hallucinations.
History should assess onset, duration, triggers, and symptom content, including suicidal or homicidal ideation. Inquiry into recent medication changes, substance use or withdrawal, past psychiatric and medical history, and ability to care for self is essential. Collateral information from family or caregivers is often invaluable. Physical examination must include vital signs, general medical assessment, focused neurologic and cognitive evaluation, and careful screening for delirium.
The workup is guided by clinical suspicion. Basic laboratory studies often include electrolytes, renal function, glucose, calcium, CBC, thyroid-stimulating hormone, and toxicology screening. Urinalysis may identify infection. Further studies are tailored to suspected etiologies. Neuroimaging should be considered in new-onset psychosis of unclear cause, especially when focal neurologic findings are present. Lumbar puncture, EEG, or ECG (for QT monitoring) may be indicated depending on presentation.
Management prioritizes safety of the patient and staff. A calm environment, verbal de-escalation, removal of dangerous objects, and constant observation are first-line interventions. If agitation persists or safety is compromised, pharmacologic or physical restraints may be necessary. When a medical cause is suspected, the underlying condition must be identified and treated. If a primary psychiatric etiology is likely, psychiatric consultation should be obtained.
Antipsychotic medications are first-line for acute agitation associated with psychosis. Haloperidol 2–10 mg PO/IM/IV may be repeated as needed and is often combined with lorazepam for rapid tranquilization. Second-generation antipsychotics such as olanzapine, risperidone, aripiprazole, quetiapine, chlorpromazine, or ziprasidone may be used depending on clinical context. Ziprasidone requires QT monitoring. Concurrent use of IM olanzapine with IV benzodiazepines should be avoided due to risk of cardiopulmonary collapse. Benzodiazepines such as lorazepam 1–2 mg PO/IM/IV may augment sedation. Clinicians must monitor for extrapyramidal symptoms and neuroleptic malignant syndrome, characterized by hyperthermia, rigidity, autonomic instability, and altered mental status. Elderly patients with dementia-related psychosis have increased mortality risk when treated with antipsychotics.
Disposition depends on etiology and risk assessment. Patients with medical causes require admission to an appropriate medical service. Patients with psychiatric causes may require psychiatric hospitalization if they are a danger to themselves or others, are gravely disabled, or have new-onset psychosis after medical causes are excluded. Discharge may be appropriate if symptoms resolve, the patient is medically stable, not dangerous, and able to care for themselves, with prompt outpatient psychiatric follow-up arranged.
Psychosis should never be presumed to be purely psychiatric without appropriate evaluation for reversible medical causes, even in patients with known psychiatric illness. Visual or multisensory hallucinations, fluctuating mental status, or abnormal vital signs warrant thorough medical assessment. Early identification and treatment of reversible causes can significantly improve outcomes.
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