In young patients (age 18 to 30) with new-onset psychosis, consider drug-induced psychosis; PCP, lysergic acid diethylamide, and methamphetamine intoxication and withdrawal can lead to psychotic presentations. Additionally, comorbid substance use is common among patients with primary psychotic disorders. One study found 37% of first-episode psychotic patients misused drugs or alcohol, similar to the lifetime rate of patients with chronic psychotic disorders.23,24 Check urine and serum toxicology screens and obtain relevant substance use history. Brain MRI may be considered for patients with first presentation of psychosis; however, there is little evidence to support head CT imaging unless there is known head trauma.25 Electroencephalography and lumbar puncture can be considered if clinically indicated.
Further psychiatric evaluation
Obtaining a psychiatric history is necessary to determine the etiology of the acute psychotic presentation. The timing and duration of psychotic symptoms are key. Acute symptom onset with fluctuating course and impaired attention suggests a delirious process. A gradual decline in functioning over several months to years in a young person suggests a first episode of a psychotic disorder (eg, schizophrenia). Drug abuse is common among young persons with a psychotic disorder and a positive drug screen for a psychogenic substance does not exclude a primary psychotic disorder.
If a patient has a history of schizophrenia, bipolar disorder, or psychotic depression, acutely worsening psychosis may be considered an acute or chronic presentation. Even in patients diagnosed with a psychotic illness, it is necessary to determine the cause of symptom exacerbation. Medication nonadherence (which can be partial), substance use, psychosocial stressors, or underlying medical illness should be considered. Collateral information from family or friends may be crucial to understanding a patient’s presentation.
Safe disposition
Patients who pose a risk of harm to themselves or others or who are so impaired by their psychosis that they cannot care for themselves generally should be admitted to an inpatient psychiatric facility. For some psychotic patients who are agreeable to treatment and not prone to violence, less restrictive settings—such as a crisis intervention unit or respite facility—may be appropriate. A patient with first-episode psychosis could be admitted for further diagnostic clarification and treatment initiation. Manic patients often have no insight into their illness and may need hospitalization for containment and assurance of medication adherence. Goals of inpatient care include initiating or resuming pharmacologic treatment to reduce psychotic symptoms and beginning the recovery process. Response rates—defined as ≥20% improvement in total score on a psychopathology scale such as the Positive and Negative Syndrome Scale—will vary, but can take ≥4 weeks in some patients with first-episode schizophrenia.26 However, most patients will be stabilized and ready for discharge before 4 weeks. Family education and alliance building with the patient and family are important during hospitalization.
Related Resources
- Schwartz S, Weathers, M. The psychotic patient. In: Riba MB, Ravindranath D, eds. Clinical manual of emergency psychiatry. Arlington, VA: American Psychiatric Publishing, Inc.; 2010:115-140.
- American Association for Emergency Psychiatry. http://emergencypsychiatry.org.
Drug Brand Names
- Aripiprazole • Abilify
- Benztropine • Cogentin
- Diphenhydramine • Benadryl
- Divalproex • Depakote
- Haloperidol • Haldol
- Lithium • Eskalith, Lithobid
- Lorazepam • Ativan
- Midazolam • Versed
- Olanzapine • Zyprexa
- Risperidone • Risperdal
- Ziprasidone • Geodon
Disclosures
Dr. Freudenreich receives grant or research support from Beacon Health Strategies, Global Medical Education, MGH Psychiatry Academy, Optimal Medicine, Pfizer Inc., and PsychoGenics.
Drs. Brown and Stoklosa report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.