Acute Psychosis Summary

Definition

  • Alterations in perception, thoughts, mood, behavior
  • Positive: hallucinations, delusions
  • Negative: blunting, social withdrawal

Key Disorders

  • Schizophrenia (most common)
  • Schizoaffective disorder
  • Drug-induced psychosis
  • Persistent delusional disorder

Risk Assessment

  • Assess risk to self and others
  • Suicide risk, command hallucinations
  • History of violence, substance use
  • High risk → same-day specialist assessment

Management

  • No antipsychotics without specialist
  • Comprehensive care planning
  • Medication monitoring
  • Therapeutic interventions

Differential Diagnosis

  • Mood disorders with psychosis
  • Substance-induced
  • Medical conditions
  • PTSD, OCD, autism spectrum

Complications

  • Premature death, suicide risk
  • Physical health comorbidities
  • Social exclusion
  • Substance misuse

Acute Psychosis

Assessment and management of psychotic disorders

Introduction

The term 'psychosis' encompasses a number of symptoms associated with significant alterations to a person's perception, thoughts, mood, and behaviour.

Individuals experiencing psychosis will have a different combination of symptoms, which may include:

Positive Symptoms

  • Hallucinations: Perceptions in the absence of stimulus
    • Auditory (most common)
    • Visual, olfactory, gustatory, tactile
  • Delusions: Fixed or falsely-held beliefs
    • Delusions of reference
    • Delusions of control
    • Delusions of persecution
  • Disorganised behaviour, speech, and/or thoughts

Negative Symptoms

  • Emotional blunting
  • Reduced speech
  • Loss of motivation
  • Self-neglect
  • Social withdrawal

Psychotic Disorders

Schizophrenia

The most common psychotic disorder. ICD-10 criteria require symptoms present most of the time for 1 month or more:

  • One or more of:
    • Specific hallucinatory voices
    • Thought echo, insertion, withdrawal, broadcasting
    • Delusions of control, influence, passivity
    • Persistent culturally inappropriate delusions
  • Or any two of:
    • Persistent hallucinations with other features
    • Thought disorder (incoherence, neologisms)
    • Catatonic behavior
    • Negative symptoms
    • Significant behavior change

Other Psychotic Disorders

  • Schizoaffective disorder: Symptoms of schizophrenia and mood disorder equally prominent
  • Drug-induced psychosis: Substance-induced, usually remits within a month of cessation
  • Persistent delusional disorder: Most pervasive symptom is delusion

Differential Diagnoses

Psychiatric Conditions

  • Severe affective (mood) disorders with psychotic symptoms
  • Post-traumatic stress disorder (PTSD)
  • Obsessive compulsive disorder (OCD)
  • Autism spectrum disorder or communication disorders

Medical Conditions

  • Drug-induced psychosis (cannabis, stimulants, medications)
  • Sepsis
  • Cerebrovascular disease
  • HIV, syphilis
  • Cerebral tumours
  • Temporal lobe epilepsy

Risk Assessment

Critical Assessment Required

For all people with psychotic symptoms, undertake an assessment of the risk of harm to the person and/or others.

Risk to Self

  • History of self-harm
  • Suicidal ideation and plans
  • Feelings of hopelessness
  • Substance misuse
  • Likelihood of accidental injury
  • 'Command' hallucinations
  • Level of family/social support
  • Timing (highest risk around psychotic episode and after discharge)

Risk to Others

  • Potential for neglect of dependents
  • Risk to public
  • Previous history of violence/confrontation
  • Weapon carrying
  • Stimulant drug use
  • Delusions focused on particular individual

High Risk Management

For people judged to be at high risk of harm to themselves or others, arrange same-day specialist mental health assessment. If admission needed, attempt voluntary admission first. Compulsory admission under Mental Health Act may be necessary if declined.

Management

Important Note

Do not start antipsychotic drug treatment while awaiting specialist assessment unless under advice from a consultant psychiatrist.

Secondary Care Management

People diagnosed with a psychotic disorder are likely to be offered:

Therapeutic Interventions

  • Therapeutic trial of oral antipsychotic (first or second-generation)
  • Family intervention for relatives
  • Individual CBT
  • Arts therapies

Monitoring & Care Planning

  • Health monitoring for at least 12 months
  • Monitoring effects of antipsychotic treatment
  • Comprehensive care plan defining roles
  • Crisis plan
  • Advance statement
  • Key clinical contacts for emergencies

Complications

Medical Complications

  • Premature death
  • Increased suicide and self-harm risk
  • Cardiovascular disease
  • Type 2 diabetes
  • Smoking-related illness
  • Malignancy
  • Infections (HIV, hepatitis C, tuberculosis)

Psychosocial Complications

  • Consequences of disinhibition
  • Impaired social functioning
  • Social exclusion
  • Substance misuse