Acute Psychosis

Introduction | Common Causes | Recognition and Detection | Bedside Investigations | Management | References

Introduction

Acute psychosis is a mental health condition characterised by a sudden onset of symptoms such as hallucinations, delusions, disorganised thinking, and impaired reality testing. It is a psychiatric emergency that requires prompt assessment and intervention. The underlying causes can vary widely, and effective management depends on identifying and treating the underlying cause.

Common Causes

Acute psychosis can be caused by a range of medical, psychiatric, and substance-related conditions. Common causes include:

• Primary Psychiatric Disorders:
  • Schizophrenia: A chronic psychiatric disorder that often presents with acute psychotic episodes.
  • Bipolar Disorder: During manic or depressive episodes, individuals may experience psychotic symptoms.
  • Major Depressive Disorder with Psychotic Features: Severe depression can be accompanied by delusions or hallucinations.
• Medical Conditions:
  • Infections: Urinary tract infections (UTIs), especially in elderly patients, can lead to delirium and acute psychosis.
  • Electrolyte Imbalances: Conditions such as hyponatraemia can cause confusion and psychosis.
  • Endocrine Disorders: Thyroid dysfunction, particularly hyperthyroidism or hypothyroidism, can precipitate psychotic symptoms.
  • Neurological Conditions: Stroke, epilepsy, and brain tumours can present with acute psychosis.
• Substance-Induced Psychosis:
  • Alcohol Withdrawal: Delirium tremens, a severe form of alcohol withdrawal, can cause hallucinations and delusions.
  • Illicit Drugs: Use of substances such as amphetamines, cocaine, cannabis, and hallucinogens can induce psychosis.
  • Prescription Medications: Certain medications, including corticosteroids and anticholinergics, can cause psychotic symptoms, especially at high doses or in sensitive individuals.

Recognition and Detection

Early recognition of acute psychosis is crucial, particularly when caused by medical conditions such as a UTI in the elderly:

• Hallucinations: Patients may report hearing voices or seeing things that are not present.
• Delusions: Fixed, false beliefs that are not aligned with reality, such as paranoid thoughts or grandiosity.
• Disorganised Thinking: Speech may be incoherent, tangential, or irrelevant.
• Agitation or Aggression: Patients may become irritable, agitated, or aggressive, especially when their delusions are challenged.
• Confusion and Altered Mental Status: In cases like UTI-induced delirium in the elderly, the patient may present with confusion, disorientation, and fluctuating levels of consciousness.

Bedside Investigations

When assessing a patient with acute psychosis, especially in cases where an organic cause is suspected, several bedside investigations should be performed:

• Urinalysis: A simple dipstick test can help detect a urinary tract infection (UTI) in elderly patients. Look for signs of infection such as leukocytes, nitrites, and blood in the urine.
• Blood Glucose: Check for hypoglycaemia or hyperglycaemia, as both can cause altered mental states and psychosis.
• Electrolyte Panel: Assess for electrolyte imbalances such as hyponatraemia or hypercalcaemia, which can contribute to psychosis.
• Thyroid Function Tests: Evaluate for thyroid dysfunction, as both hyperthyroidism and hypothyroidism can precipitate psychosis.
• ECG: If a patient is on antipsychotic medications or presents with symptoms of delirium, an ECG can help identify any cardiac abnormalities, particularly QT prolongation.
• Drug Screening: Consider a urine drug screen to identify the presence of illicit substances or medications that could be causing the psychosis.

Management

The management of acute psychosis depends on identifying and treating the underlying cause. General management strategies include:

1. Treating Underlying Causes

• Infections: In cases of UTI-induced psychosis, particularly in the elderly, prompt treatment with appropriate antibiotics is essential. Consider IV fluids and supportive care as needed.
• Electrolyte Imbalances: Correct any detected imbalances, such as administering sodium for hyponatraemia or fluids for hypercalcaemia.
• Endocrine Disorders: Manage underlying endocrine conditions, such as administering levothyroxine for hypothyroidism or beta-blockers and antithyroid medications for hyperthyroidism.
• Substance Withdrawal: For alcohol withdrawal, consider benzodiazepines to prevent or treat delirium tremens. For other substances, manage withdrawal symptoms and provide supportive care.

2. Symptomatic Treatment

• Antipsychotics: Medications such as haloperidol, olanzapine, or risperidone may be used to manage acute psychotic symptoms. Dosing should be carefully monitored, particularly in elderly patients, due to the risk of side effects.
• Sedatives: In cases of severe agitation or aggression, short-term use of sedatives such as lorazepam may be necessary to calm the patient.
• Supportive Care: Ensure a safe environment for the patient, with minimal stimulation. Reassurance and a calm approach are essential to reduce distress.

3. Referral to Specialist Care

• Urgent Psychiatric Referral: If the psychosis is severe or if there is a risk of harm to the patient or others, an urgent referral to psychiatric services is required.
• Memory Clinic or Neurology Referral: If the patient has recurrent episodes of confusion and psychosis, particularly in the context of cognitive decline, referral to a memory clinic or neurologist for further assessment may be appropriate.

References

1. National Institute for Health and Care Excellence (2024) Psychosis and Schizophrenia in Adults: Prevention and Management. Available at: https://www.nice.org.uk/guidance/cg178 (Accessed: 26 August 2024).
2. Royal College of Psychiatrists (2024) Management of Delirium and Acute Psychosis. Available at: https://www.rcpsych.ac.uk/ (Accessed: 26 August 2024).
3. British National Formulary (2024) Antipsychotics and Sedatives. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).

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