Acute Psychosis

Quick Answer

One-liner: Acute psychosis is a psychiatric emergency characterized by loss of contact with reality (delusions, hallucinations, disorganized thought) requiring rapid medical exclusion of organic causes, risk assessment, and de-escalation with judicious chemical sedation when indicated.

Psychosis describes a syndrome of disordered thought, perception, and reality testing. In the ED, the priority is threefold: (1) Exclude organic causes (delirium, drugs, neuro), (2) Assess risk (violence, self-harm, absconding), and (3) Manage agitation safely using verbal de-escalation first, followed by chemical sedation (olanzapine 10mg PO/IM, droperidol 5-10mg IM, haloperidol 5mg IM + midazolam 5mg IM) or physical restraint as last resort. First-episode psychosis (FEP) requires lower doses and early psychiatric consultation. Indigenous patients need culturally safe care with interpreter/liaison services. Remote/rural EDs must balance stabilization with RFDS retrieval logistics.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Limbic system (amygdala, hippocampus), prefrontal cortex, basal ganglia (extrapyramidal side effects)
• Physiology: Dopamine hypothesis (mesolimbic, mesocortical, nigrostriatal, tuberoinfundibular pathways), serotonin in atypical antipsychotics
• Pharmacology: First-generation antipsychotics (D2 antagonism, EPS), second-generation antipsychotics (5-HT2A/D2 antagonism), benzodiazepines (GABA-A agonism), anticholinergics (muscarinic blockade for dystonia)

Fellowship Exam Relevance

• Written: Organic vs functional differential (VINDICATE), risk assessment tools (HCR-20, START, DASA), Mental Health Act criteria by state, chemical sedation protocols, first-episode psychosis management
• OSCE: Mental state examination, breaking bad news (new schizophrenia diagnosis), communication with agitated patient, involuntary detention documentation, consultation-liaison psychiatry referral
• Key domains tested: Medical Expert (differential diagnosis, organic exclusion), Communicator (de-escalation, family discussion), Collaborator (MH team, police), Leader (team safety, restraint coordination), Professional (involuntary treatment ethics), Cultural Competence (Indigenous mental health)

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Key Points

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Epidemiology

Australian/NZ Specific

• Aboriginal and Torres Strait Islander: 2-3x higher hospitalization for schizophrenia, later presentation (delayed access), lower treatment engagement [8]
• Māori: 1.7x higher psychosis prevalence (NZ), cultural idioms of distress may differ (e.g., spirit possession), whānau involvement critical [9]
• ED presentations: Psychosis accounts for 2-3% of ED mental health presentations; 40% require involuntary admission [10]
• Regional variations: Higher prevalence in urban centers (Melbourne, Sydney, Auckland), cannabis-induced psychosis more common in Far North Queensland and remote NT [11]

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Pathophysiology

Mechanism

Dopamine Hypothesis (Revised):

• Mesolimbic pathway (ventral tegmental area → nucleus accumbens): Hyperactivity → positive symptoms (hallucinations, delusions)
• Mesocortical pathway (VTA → prefrontal cortex): Hypoactivity → negative symptoms (flat affect, avolition, alogia)
• Nigrostriatal pathway (substantia nigra → striatum): D2 blockade by antipsychotics → extrapyramidal side effects (dystonia, akathisia, parkinsonism)
• Tuberoinfundibular pathway (hypothalamus → pituitary): D2 blockade → hyperprolactinemia (galactorrhea, amenorrhea)

Glutamate Hypothesis:

• NMDA receptor hypofunction (explains ketamine/PCP-induced psychosis)
• Explains negative and cognitive symptoms better than dopamine hypothesis

Neurodevelopmental Model:

• Genetic predisposition (heritability 60-80%)
• Perinatal insults (hypoxia, infection)
• Adolescent pruning abnormalities → psychosis onset in late adolescence/early adulthood

Pathological Progression

Prodrome (weeks-months) → First-Episode Psychosis → Treatment Response/Non-response → Relapse/Chronic Course
    ↓                           ↓                              ↓                              ↓
Social withdrawal          Positive symptoms          FGA/SGA trial                 Poor insight
Cognitive deficits         Negative symptoms          40-60% response              Medication non-adherence
Functional decline         Disorganization            20% treatment-resistant      Substance use
                                                       "Critical period" 2-5y

Why It Matters Clinically

• First 2-5 years are critical: Early intervention improves long-term outcomes, reduces DUP (duration of untreated psychosis) [12]
• Substance-induced psychosis can unmask schizophrenia: Cannabis, methamphetamine trigger earlier onset in vulnerable individuals [13]
• Negative symptoms most disabling: Flat affect and avolition cause greater functional impairment than hallucinations [14]
• Dopamine pathways explain side effects: Understanding nigrostriatal pathway predicts EPS (dystonia in first 48h, akathisia 2-7 days, parkinsonism weeks-months, tardive dyskinesia months-years)

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Clinical Approach

Recognition

Triggers for "Psychosis" in ED Triage:

• Bizarre behavior, responding to internal stimuli
• Paranoid or persecutory beliefs
• Disorganized speech ("word salad", neologisms)
• Agitation or aggression
• Police escort, Mental Health Act assessment
• Known schizophrenia with medication non-adherence

Critical Question: Organic or Functional?

Initial Assessment

Primary Survey (Agitated Patient)

• A: Airway patent? (assess if GCS reduced from sedation/intoxication)
• B: RR greater than 20 or below 10? (sympathomimetic vs sedative-hypnotic), SpO2 greater than 94%
• C: HR, BP (tachycardia/hypertension → sympathomimetic vs anticholinergic; hypotension → antipsychotic/sedative)
• D: GCS, pupils (mydriasis → sympathomimetic/anticholinergic; miosis → opioid), temperature (hyperthermia → NMS, serotonin syndrome, excited delirium)
• E: Diaphoresis (sympathomimetic), dry skin (anticholinergic), track marks (IV drug use), tremor

Safety Assessment:

• Environmental: Remove potential weapons, ensure exit access for staff
• Restraint: Security/police present if required, restraint equipment ready
• Observation: 1:1 special if high absconding/violence risk

History

Key Questions

VINDICATE Mnemonic for Organic Causes

Red Flag Symptoms

Examination

General Inspection

• Appearance: Self-care (unkempt → negative symptoms), bizarre clothing/makeup
• Behavior: Responding to internal stimuli (talking/gesturing to no one), guarded posture, poor eye contact, psychomotor agitation/retardation
• Speech: Rate (pressured in mania, slow in depression), volume, disorganized ("word salad", tangential, circumstantial)

Mental State Examination

Physical Examination (Exclude Organic Causes)

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Investigations

Immediate (Resus Bay / High Acuity)

Standard ED Workup (First-Episode Psychosis)

Advanced/Specialist (Selected Patients)

Point-of-Care Ultrasound

• Limited role in psychosis (unlike delirium where POCUS cardiac/lung useful for sepsis)
• Bladder scan: Urinary retention from anticholinergic drugs or psychogenic polydipsia
• Ovarian teratoma: Transabdominal pelvic if anti-NMDA receptor encephalitis suspected (low yield, formal imaging better)

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Management

Immediate Management (First 10 minutes)

1. SAFETY: Remove weapons, ensure exit access for staff, security/police if high violence risk (0-2 min)
2. ORGANIC EXCLUSION: Capillary glucose, vital signs, brief neuro exam, ECG (2-5 min)
3. RISK ASSESSMENT: Violence (command hallucinations, paranoia), self-harm, absconding (5-10 min)
4. DE-ESCALATION: Attempt verbal de-escalation (Project BETA 10 domains) before chemical sedation (ongoing)
5. OBSERVATION: Allocate 1:1 special if high risk, remove sharps/ligature points

Verbal De-escalation (Project BETA) [15]

10 Domains (evidence-based):

1. Respect personal space: 2 arm lengths (1.5-2 meters), avoid "boxing in"
2. Non-threatening posture: Hands visible, side-on stance (not frontal), sit if safe
3. Establish verbal contact: "My name is Dr. X, I'm here to help"
4. Be concise: Short sentences, avoid jargon
5. Identify wants and feelings: "You seem upset, can you tell me what's wrong?"
6. Listen closely: Active listening, validate feelings (not delusions)
7. Agree or agree to disagree: "I understand you believe X, can we work together?"
8. Set clear limits: "I need you to sit down so we can talk"
9. Offer choices: "Would you prefer a tablet or an injection to help you relax?"
10. Debrief patient and staff: After resolution, discuss what happened

When de-escalation fails: Progress to chemical sedation

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Chemical Sedation

First-Line Options (Oral if Cooperative)

Parenteral Options (Non-Cooperative / Severe Agitation) [16]

ACEM Recommended Approach

Undifferentiated agitation (unknown etiology):

• First-line: Droperidol 10mg IM OR Olanzapine 10mg IM (if cooperative, PO wafer preferred)
• Rescue: Droperidol 5mg IM q30min (max 20mg) OR Midazolam 5mg IM q15min

Known psychosis / FEP:

• First-line: Olanzapine 10mg PO wafer (5mg if FEP) OR Olanzapine 10mg IM
• Avoid haloperidol in FEP (high EPS risk → poor long-term engagement)

Excited delirium / Sympathomimetic:

• First-line: Droperidol 10mg + Midazolam 10mg IM (DORM-II protocol) [19]
• Alternative: Ketamine 4-5 mg/kg IM (if refractory, intubation likely)

Substance-induced psychosis (cannabis, methamphetamine):

• First-line: Midazolam 5-10mg IM OR Droperidol 10mg IM
• Avoid antipsychotics if pure intoxication (will resolve with time)

Monitoring Post-Sedation

• Vital signs: q15min x 1 hour, then q30min x 2 hours
• SpO2: Continuous if IM benzodiazepine used
• Level of sedation: RASS scale (target -1 to 0, calm but rousable)
• Side effects: EPS (dystonia, akathisia), hypotension, prolonged QTc

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Physical Restraint (Last Resort) [20]

Indications:

• Imminent danger to self/others
• De-escalation and chemical sedation failed or unsafe to administer
• Patient attempting to abscond with high risk

Principles:

• Team approach: Minimum 5 people (1 per limb + 1 head), designated leader
• Communication: Explain to patient ("We need to keep you and us safe")
• Technique: Supine (NOT prone → positional asphyxia), monitor airway/breathing continuously
• Limb restraints: Soft restraints to bed frame, 1 limb free if safe
• Monitoring: 1:1 observation, vital signs q15min, check limb perfusion, offer food/water/toileting q2h
• Time-limited: Restraints removed as soon as safe, maximum 4 hours before medical review

Complications:

• Positional asphyxia: Prone restraint + obesity + chest compression → death (avoid prone)
• Rhabdomyolysis: Prolonged struggle, excited delirium → CK, myoglobinuria
• Thromboembolism: Prolonged immobility → DVT/PE
• Psychological trauma: PTSD, loss of trust, disengagement from care

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Mental Health Act and Involuntary Treatment

Criteria for Involuntary Detention (varies by state/NZ):

General principles (all jurisdictions):

1. Mental illness present (psychosis, severe depression, mania)
2. Risk criterion met:
   • Imminent risk of serious harm to self OR
   • Imminent risk of serious harm to others OR
   • Inability to care for self (food, shelter, safety)
3. Refusal of voluntary treatment
4. No less restrictive alternative

State-Specific Variations:

ED Doctor Role:

• Initiate assessment: Complete initial detention paperwork (varies by state)
• Medical clearance: Exclude organic causes, document fitness for psychiatric transfer
• Risk documentation: Specific behaviors/statements indicating risk
• Liaison: Contact consultation-liaison psychiatry or mental health crisis team
• Safety: Ensure 1:1 observation until psychiatric review

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Consultation-Liaison Psychiatry

When to Consult:

• All first-episode psychosis (FEP)
• Involuntary patients requiring admission
• Diagnostic uncertainty (organic vs functional)
• Suicidal ideation with psychosis
• Treatment-resistant agitation
• Discharge planning for known psychosis

Information to Provide:

1. Demographics: Age, sex, Aboriginal/Torres Strait Islander/Māori status
2. Presentation: Chief complaint, timeline, triggering events
3. Mental state examination: Detailed documentation
4. Risk assessment: Violence, self-harm, absconding (use structured tool if available)
5. Medical exclusion: Investigations completed, results, organic causes ruled out
6. Medications given: Doses, times, response
7. Collateral: Family/police/ambulance information, previous psychiatric history
8. Social: Accommodation, supports, substance use
9. Legal status: Voluntary or involuntary (specify Mental Health Act section)

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Disposition

Admission Criteria

Psychiatric Admission:

• First-episode psychosis (all cases)
• Involuntary patient under Mental Health Act
• Suicidal ideation or recent attempt
• Acute risk of violence to others
• Inability to care for self (homelessness, no supports)
• Treatment non-adherence with deterioration
• Comorbid substance withdrawal requiring monitoring

Medical Admission (before psychiatric transfer):

• Organic cause requiring treatment (encephalitis, stroke, metabolic)
• Medically unstable (sepsis, rhabdomyolysis, electrolyte disturbance)
• Severe side effects from medication (NMS, dystonia requiring ongoing monitoring)

ICU/HDU Criteria

• Excited delirium with hyperthermia + rhabdomyolysis (CK greater than 5,000, AKI)
• Neuroleptic malignant syndrome (temp greater than 38°C, rigidity, CK greater than 1,000, autonomic instability)
• Post-sedation respiratory depression requiring intubation
• Serotonin syndrome (hyperthermia, clonus, autonomic instability)

Discharge Criteria (Rare in Acute Psychosis)

Consider discharge ONLY if:

• Substance-induced psychosis (cannabis, methamphetamine) with complete resolution and normal mental state
• Patient calm, cooperative, insight present
• No suicidal or homicidal ideation
• Reliable supports at home
• Psychiatry/GP follow-up arranged within 24-48 hours
• Clear discharge plan and red flags discussed

Red Flags to Return:

• Thoughts of harming self or others
• Unable to eat, drink, sleep for 24 hours
• Worsening paranoia or hallucinations
• Side effects from medication (stiffness, tongue twisting, unable to sit still)

Follow-up

• Psychiatry: Within 24-48 hours (outpatient clinic or crisis team)
• GP: Within 1 week (medication monitoring, social supports)
• Early Psychosis Intervention Service (EPIS): Referral for all FEP (available in major metro centers)
• Community mental health team: Ongoing case management
• Medication: Ensure 3-7 day supply at discharge (antipsychotic, anticholinergic if needed)

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Special Populations

Paediatric Considerations (below 18 years)

Key Differences:

• FEP rare before age 13: Consider organic causes (encephalitis, autoimmune, Wilson's, drug-induced) more strongly
• Medication doses (olanzapine): 2.5-5mg PO/IM (max 10mg/24h), higher EPS risk in children
• Legal: Parental consent required unless emergency (varies by state), child protection considerations if neglect/abuse suspected
• Admission: Paediatric consultation + child psychiatry (not adult psychiatry)

Pregnancy

Risks:

• Postpartum psychosis: 1-2 per 1,000 births, onset 2-4 weeks postpartum, psychiatric emergency (infanticide risk 4%, suicide risk 5%)
• Medication safety:
  • "Preferred: Haloperidol (lowest risk FGA), quetiapine (low risk SGA)"
  • "Avoid: Benzodiazepines first trimester (cleft palate), valproate (neural tube defects)"
• Consultation: Obstetrics + psychiatry for all pregnant/postpartum psychosis

Elderly (greater than 65 years)

Key Considerations:

• Organic causes more likely: Delirium (UTI, pneumonia, medications), dementia with psychosis (Lewy body), late-onset schizophrenia (paraphrenia)
• Medication sensitivity: Start low (olanzapine 2.5mg, haloperidol 0.5-1mg), high falls risk, prolonged QTc risk
• Polypharmacy: Review medication list (anticholinergics, steroids, levodopa)
• Medical comorbidities: CVD, renal impairment alter drug clearance

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• Aboriginal/Torres Strait Islander: 2-3x higher hospitalization for schizophrenia, 1.5x higher involuntary admission rate [8]
• Māori: 1.7x higher psychosis prevalence, younger age at first presentation [9]
• Social determinants: Trauma, intergenerational trauma (Stolen Generations, colonization), poverty, substance use (cannabis, alcohol)

Cultural Safety:

• Language: Request interpreter even if patient speaks English (te reo Māori, Aboriginal languages)
• Aboriginal Liaison Officer / Māori Health Worker: Involve early, facilitate communication with whānau/family
• Family involvement: Central to care, decision-making (collective not individual in Māori culture - whānau ora model)
• Cultural idioms of distress: Spirit possession, "makutu" (Māori sorcery), "bone pointing" may present as psychosis but require cultural understanding
• Racism and discrimination: Higher rates of seclusion/restraint in Indigenous patients → conscious effort to avoid bias [21]

Remote/Rural Considerations:

• Access barriers: Long distances to services, limited transport, cost
• Workforce: Few Indigenous mental health workers, high turnover
• Community-based care: Stronger in remote areas than urban (extended family, elders)
• Forced removal for treatment: Trauma from removal from "country" and community → balance safety with cultural harm

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Mental State Examination in Acute Psychosis

Format: History/Examination Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

You are the ED registrar. A 24-year-old man has been brought to ED by police after being found wandering the streets talking to himself. Perform a mental state examination and present your findings to the examiner.

Examiner Instructions: The candidate should conduct a systematic mental state examination covering appearance, behavior, speech, mood, affect, thought form, thought content, perception, cognition, and insight. The patient (actor) has first-episode psychosis with auditory hallucinations and paranoid delusions. Observe the candidate's communication skills (non-threatening approach, appropriate questions) and ability to structure the MSE.

Actor/Patient Brief: You are a 24-year-old man who believes the government is tracking you through your phone. You hear voices (male and female) commenting on your actions ("He's sitting down now," "He's looking at the doctor"). You are suspicious of the doctor and hospital staff but willing to answer questions. You haven't slept for 3 days. You feel anxious and frightened. You believe you are not ill, just being persecuted.

Key phrases to use:

• "Why are you asking me these questions? Are you working for them?"
• "The voices tell me what I'm doing, like right now they're saying I'm talking to you"
• "I'm not sick, the government is following me, that's not a delusion, it's real"

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Identifying hallucinations (auditory vs visual), differentiating delusions from overvalued ideas, assessing insight ("Do you think you have a mental illness?")

Model MSE Presentation: "This is a 24-year-old man brought by police. On MSE: Appearance - casually dressed, poor hygiene, appears tired. Behavior - guarded posture, limited eye contact, occasionally pauses mid-sentence as if listening. Speech - normal rate and volume, coherent. Mood - 'anxious and frightened'. Affect - anxious, congruent with mood. Thought form - linear and goal-directed, no formal thought disorder. Thought content - paranoid delusions (government tracking via phone), no suicidal or homicidal ideation currently. Perception - auditory hallucinations (third-person running commentary), no visual hallucinations. Cognition - alert and oriented to person, place, and time; attention intact. Insight - absent, does not believe he has a mental illness. Overall, this is consistent with first-episode psychosis, likely schizophreniform disorder or drug-induced psychosis. I would exclude organic causes (drug screen, metabolic panel, CT if indicated) and obtain psychiatry consultation."

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Station 2: Communication - Breaking Bad News (New Schizophrenia Diagnosis)

Format: Communication Time: 11 minutes Setting: ED family room

Candidate Instructions:

You are the ED registrar. You have assessed a 22-year-old man with first-episode psychosis. The psychiatry team has reviewed him and made a provisional diagnosis of schizophrenia. He will be admitted involuntarily. His mother is waiting in the family room. Please explain the diagnosis, admission plan, and answer her questions.

Examiner Instructions: Assess the candidate's ability to break bad news using a structured approach (SPIKES protocol or similar), communicate empathetically, explain mental illness in lay terms, and address the mother's concerns without providing false reassurance.

Actor/Mother Brief: You are the 50-year-old mother of the patient. You are shocked and frightened. You don't know much about schizophrenia except stereotypes from movies ("crazy people"). You are worried about: (1) Is this your fault? (bad parenting?); (2) Will he be violent?; (3) Will he recover?; (4) Why does he have to stay in hospital against his will?

Key phrases to use:

• "Schizophrenia? Isn't that like split personality?"
• "Did I do something wrong? I always loved him..."
• "Will he be violent? I saw on TV..."
• "Why can't he just come home and I'll make sure he takes the medication?"

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Empathy (acknowledging mother's distress), correcting misconceptions about schizophrenia (split personality, inevitable violence), explaining involuntary admission rationale (safety, not punishment)

Model Approach:

1. Introduction: "Mrs. Smith, I'm Dr. X, the emergency registrar who's been looking after your son. Thank you for waiting. Is it okay if we sit down? I want to update you on what's happening."
2. Assess understanding: "What have the police or other staff told you so far?"
3. Warning shot: "I'm afraid the psychiatry team has some serious concerns about your son's mental health."
4. Diagnosis: "They think he has a condition called schizophrenia. This is a mental illness where the brain's chemistry is out of balance, causing him to hear voices and believe things that aren't real. It's not the same as 'split personality' which is a different condition."
5. Address blame: "This is not your fault. Schizophrenia is a biological illness with genetic and environmental factors. Nothing you did as a parent caused this."
6. Address violence: "Most people with schizophrenia are not violent. In fact, they are more likely to be victims of violence than perpetrators. The media portrays a very inaccurate picture."
7. Prognosis: "With medication and support, many people with schizophrenia recover well. About 60-80% will respond to medication and can live independently. The first few years are important for treatment, so early intervention improves outcomes."
8. Involuntary admission: "I know it's hard to hear that he has to stay in hospital even though he doesn't want to. The reason is that he doesn't believe he's unwell, and without treatment, he's at risk of harming himself or not being able to care for himself. Once he's stable on medication, he'll be able to leave."
9. Support: "I'll provide you with the contact details for the mental health unit and support organizations like SANE Australia. You're not alone in this."

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Station 3: Resuscitation - Managing Excited Delirium

Format: Resuscitation Time: 11 minutes Setting: Resuscitation bay

Candidate Instructions:

You are the ED registrar. Ambulance has brought a 35-year-old man found running naked on the street, highly agitated, fighting paramedics. Suspected methamphetamine use. HR 150, BP 180/110, Temp 39.5°C, RR 28, SpO2 95% RA. He is shouting and trying to get off the trolley. A nurse and security guard are available. Please manage this patient.

Examiner Instructions: This is excited delirium, a life-threatening emergency requiring rapid sedation and monitoring for rhabdomyolysis and hyperthermia. Assess the candidate's ability to: (1) Recognize excited delirium; (2) Ensure team safety; (3) Direct rapid chemical sedation; (4) Monitor for complications (hyperthermia, rhabdomyolysis, cardiac arrest); (5) Communicate clearly with team.

Nurse/Security Brief: The patient is extremely agitated, resisting restraint, shouting incoherently. Security has managed to get him on the trolley but he keeps trying to sit up. You await the doctor's instructions. If asked, you will assist with IM injection or IV access, but patient is very combative.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators: Recognizing excited delirium (not just "agitated patient"), anticipating complications (rhabdomyolysis → AKI, hyperthermia → seizures/arrest), choosing appropriate sedation (droperidol + midazolam OR ketamine, not haloperidol alone)

Model Performance:

1. Situational awareness: "This is excited delirium from sympathomimetic drugs, high risk of sudden cardiac arrest, rhabdomyolysis, and hyperthermia. We need to sedate rapidly and monitor closely."
2. Team safety: "I need everyone to stay safe. Security, please ensure he doesn't fall off the trolley. We're going to give medication to calm him."
3. Sedation: "Nurse, please draw up droperidol 10mg and midazolam 10mg IM. We'll inject into the deltoid or lateral thigh. Security, can you assist with gentle limb control?"
4. (After injection): "Start the timer. We should see effect in 3-7 minutes. While we wait, let's get IV access if possible and attach monitors."
5. Monitoring: "I need continuous SpO2, ECG, and BP q5min. Check temperature with a tympanic or rectal thermometer - it's 39.5 so we'll need cooling. Place ice packs to groin and axillae. Get a fan if available."
6. Investigations: "Nurse, please send: VBG (acidosis?), UEC (renal function for rhabdo), CK (muscle breakdown), troponin (cardiac ischemia), glucose (exclude hypoglycemia), FBC, LFT. Urine for myoglobin and drug screen."
7. Anticipate complications: "If his temperature doesn't come down or if he arrests, we'll need to intubate and cool actively. Let's have the intubation trolley ready."
8. (After sedation effective): "Good, he's calmer. Let's reassess in 15 minutes. Check CK result - if it's over 5,000, he'll need aggressive IV fluids and likely ICU admission for rhabdomyolysis."

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SAQ Practice

Question 1 (6 marks)

Stem: A 28-year-old man presents to the ED with acute agitation and paranoia. You suspect psychosis but must exclude organic causes.

Question: List six "red flag" features that suggest an organic cause of psychosis rather than a primary psychiatric disorder. (1 mark each)

Model Answer:

1. Age greater than 40 years at first episode (schizophrenia typically presents 18-35 years) (1 mark)
2. Visual, tactile, or olfactory hallucinations (functional psychosis predominantly auditory) (1 mark)
3. Fluctuating level of consciousness (suggests delirium) (1 mark)
4. Abnormal vital signs (fever, tachycardia, hyper/hypotension suggest infection, drugs, or metabolic) (1 mark)
5. Focal neurological deficits (suggests stroke, mass lesion, or encephalitis) (1 mark)
6. Acute onset below 48 hours (functional psychosis has gradual onset over weeks-months) (1 mark)

Alternative acceptable answers:

• Seizures (temporal lobe epilepsy, encephalitis, withdrawal)
• Reduced GCS (organic encephalopathy)
• Cognitive impairment (disorientation, memory loss beyond attention)
• Abnormal pupils (sympathomimetic, anticholinergic)

Examiner Notes:

• Accept: Any 6 of the above features
• Do not accept: "Past psychiatric history" (doesn't distinguish organic from relapse), "substance use" (too vague - need to specify acute intoxication/withdrawal features)

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Question 2 (8 marks)

Stem: A 23-year-old woman with first-episode psychosis is agitated in the ED. Verbal de-escalation has failed. You decide to use chemical sedation.

Question: a) Name two first-line pharmacological options for this patient (oral or IM). (2 marks) b) For each agent, state the dose and route. (2 marks) c) State one major side effect or contraindication for each agent. (2 marks) d) Explain why you should avoid one specific drug combination in this patient. (2 marks)

Model Answer:

a) Two first-line agents (2 marks):

1. Olanzapine (1 mark)
2. Droperidol (1 mark)

(Alternative acceptable: Risperidone, Haloperidol + midazolam combination, though olanzapine preferred for FEP)

b) Dose and route (2 marks):

1. Olanzapine 5-10mg (5mg for FEP, medication-naïve) PO wafer or IM (1 mark)
2. Droperidol 5-10mg IM (1 mark)

c) Side effects/contraindications (2 marks):

1. Olanzapine: Hypotension, sedation, or metabolic syndrome long-term; contraindication: do not combine with IM benzodiazepines (cardiorespiratory depression) (1 mark)
2. Droperidol: Extrapyramidal side effects (dystonia, akathisia), QTc prolongation (historical concern, less supported by evidence); relative contraindication: QTc greater than 500ms (1 mark)

d) Drug combination to avoid (2 marks): Never combine IM olanzapine with IM benzodiazepines (e.g., midazolam, lorazepam) due to risk of severe cardiorespiratory depression, hypotension, and death. Wait minimum 1 hour between doses if both required. (2 marks)

Examiner Notes:

• Accept: Olanzapine/droperidol as first-line (evidence-based for FEP)
• Do not accept: Haloperidol monotherapy as first-line for FEP (high EPS risk, poor long-term engagement)
• Partial credit: 1 mark if candidate states "IM olanzapine + IM benzo" without specifying mechanism (cardiorespiratory depression)

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Question 3 (8 marks)

Stem: A 30-year-old Aboriginal man with known schizophrenia presents to a remote Northern Territory clinic with acute psychosis after stopping medication. He is hearing command hallucinations to harm his neighbor. The nearest psychiatry service is 800 km away.

Question: a) List four factors you would assess to determine his risk of violence. (2 marks) b) What are the criteria for involuntary detention under the Mental Health Act in your jurisdiction? (3 marks) c) What are two culturally specific considerations when managing this patient? (2 marks) d) What service would you contact for retrieval, and what information would you provide? (1 mark)

Model Answer:

a) Violence risk factors (2 marks, 0.5 each):

1. Command hallucinations (specific instruction to harm identified person) (0.5 mark)
2. Prior history of violence (strongest predictor of future violence) (0.5 mark)
3. Substance use (comorbid alcohol/cannabis increases risk) (0.5 mark)
4. Medication adherence (current non-adherence, reasons for stopping) (0.5 mark)

(Alternative acceptable: Access to weapons, relationship with victim, specific plan, insight/awareness of wrongness)

b) Mental Health Act criteria (3 marks):

1. Mental illness present (psychosis qualifies) (1 mark)
2. Risk of serious harm to self or others OR inability to care for self (command hallucinations to harm = imminent risk to others) (1 mark)
3. Refusal of voluntary treatment AND no less restrictive alternative available (1 mark)

c) Cultural considerations (2 marks, 1 each):

1. Aboriginal Health Worker involvement: Engage AHW for language interpretation, cultural liaison, and family communication (Aboriginal patients often have English as 3rd/4th language, family involvement central to care) (1 mark)
2. Forced removal trauma: Retrieval from remote community recalls Stolen Generations trauma; explain need sensitively, involve family in decision-making where possible (1 mark)

(Alternative acceptable: Cultural idioms of distress may differ, interpreter required even if English-speaking, connection to country important)

d) Retrieval service and information (1 mark): Royal Flying Doctor Service (RFDS) (0.5 mark). Provide: Patient demographics, mental state exam, risk assessment (violence/self-harm/absconding), vital signs, medications given and response, collateral history, Mental Health Act status (involuntary), need for escort/security. (0.5 mark)

Examiner Notes:

• Accept: Any 4 risk factors from standard violence risk assessment (HCR-20, DASA, START frameworks)
• Do not accept: "He has schizophrenia" (diagnosis alone doesn't confer high violence risk)
• Partial credit (b): 2 marks if candidate lists 2/3 criteria (mental illness + risk OR mental illness + refusal)
• Accept (c): Any 2 culturally specific considerations relevant to Aboriginal patients in remote NT

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Question 4 (6 marks)

Stem: First-episode psychosis (FEP) is a critical presentation in emergency medicine.

Question: a) Define the "critical period" in FEP and explain why it matters clinically. (2 marks) b) State the target duration of untreated psychosis (DUP) and why it is important. (2 marks) c) Give two reasons why second-generation antipsychotics (SGAs) are preferred over first-generation antipsychotics (FGAs) in FEP. (2 marks)

Model Answer:

a) Critical period (2 marks): The first 2-5 years after onset of psychosis (1 mark). This period determines long-term functional outcomes, symptom trajectory, and treatment adherence. Early intensive intervention (medication, psychosocial support, family education) during this period improves recovery rates and reduces relapse. (1 mark)

b) Duration of untreated psychosis (DUP) (2 marks): Target DUP: below 3 months (ideally below 1 month) (1 mark). Longer DUP (greater than 6 months) is associated with worse outcomes: poorer response to antipsychotics, greater negative symptoms, worse functional outcomes, and lower quality of life. Early intervention services aim to reduce DUP through community awareness and rapid access pathways. (1 mark)

c) SGAs preferred over FGAs in FEP (2 marks, 1 each):

1. Lower extrapyramidal side effects (EPS): FGAs have 60-80% EPS rate (acute dystonia, akathisia, parkinsonism) vs. 10-30% for SGAs. Medication-naïve FEP patients are highly sensitive to side effects, which impairs long-term treatment engagement. (1 mark)
2. Better tolerability and adherence: SGAs cause less subjective distress (akathisia is particularly distressing) → better medication adherence → lower relapse rates. First experience with antipsychotics shapes patient's willingness to continue treatment long-term. (1 mark)

(Alternative acceptable for c: SGAs may have superior efficacy for negative symptoms - though evidence mixed; lower prolactin elevation; lower tardive dyskinesia risk)

Examiner Notes:

• Accept: Critical period 2-5 years (some sources say 3-5 years, both acceptable)
• Do not accept: DUP below 6 months (this is associated with better outcomes, but target is below 3 months)
• Partial credit (c): 0.5 marks each if candidate states "lower EPS" and "better tolerability" without explaining mechanism or clinical relevance

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Australian Guidelines

Mental Health Acts (State-Specific)

NSW - Mental Health Act 2007:

• Schedule 1 Certificate: Medical practitioner + accredited person (MH nurse, psychologist, OT) can detain for 12 hours in ED
• Extension: Psychiatrist can extend to 24 hours after assessment
• Criteria: Mental illness + risk to self/others OR inability to self-care + refusal of voluntary treatment
• Appeal: Mental Health Review Tribunal within 21 days

Victoria - Mental Health Act 2014:

• Assessment Order: Registered medical practitioner can detain for 24 hours
• Temporary Treatment Order: Psychiatrist can order after assessment (max 28 days)
• Criteria: Mental illness + serious deterioration + risk to health/safety + treatment available + no less restrictive means
• Rights: Nominated person, second psychiatric opinion, regular tribunal reviews

Queensland - Mental Health Act 2016:

• Recommendation for Assessment: Doctor or authorized MH practitioner can recommend (6 hours)
• Assessment: Psychiatrist completes within 6 hours → Involuntary Treatment Order (max 21 days)
• Criteria: Mental illness + lack of capacity + treatment required + no less restrictive way
• Rights: Support person, independent patient rights adviser, tribunal review

New Zealand - Mental Health (Compulsory Assessment and Treatment) Act 1992:

• Section 109: Duly authorized officer (DAO, usually police) + doctor can detain for 6 hours
• Section 11: Assessment by psychiatrist → Compulsory Treatment Order (5 days initial, then 14 days)
• Criteria: Mental disorder + serious danger to self/others OR serious diminished capacity to care for self
• Cultural: Specific provisions for Māori (whānau involvement, cultural assessments)

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Therapeutic Guidelines Australia

Psychosis and Schizophrenia (eTG complete, 2023):

First-Episode Psychosis:

• First-line: Aripiprazole, olanzapine, paliperidone, quetiapine, or risperidone (all SGAs)
• Avoid: Clozapine (third-line due to side effects), FGAs (higher EPS)
• Dosing: Start low (e.g., olanzapine 5mg, risperidone 1-2mg), titrate slowly over 1-2 weeks
• Duration: Minimum 1-2 years after remission (relapse risk 80% if stopped below 1 year)

Acute Agitation:

• Oral: Olanzapine 10mg PO wafer, risperidone 1-2mg PO liquid
• IM: Olanzapine 10mg IM (NOT with IM benzo), haloperidol 5mg + promethazine 25mg IM, droperidol 5-10mg IM
• Benzodiazepines: Diazepam 5-10mg PO or midazolam 5mg IM for substance-induced agitation

Monitoring:

• Baseline: Weight, BMI, waist circumference, BP, glucose, lipids, prolactin, ECG
• Ongoing: Weight monthly, metabolic panel 3-monthly, movement disorder screening (AIMS)

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State-Specific Protocols

NSW Health - Management of Patients with Acute Severe Behavioural Disturbance in Emergency Departments (PD2015_043):

• De-escalation mandatory first-line (10-domain Project BETA)
• Chemical sedation: Droperidol 10mg IM OR olanzapine 10mg IM OR midazolam 10mg IM
• Physical restraint: Last resort, supine position only (NOT prone), 1:1 observation, q15min vital signs
• Documentation: Specific behaviors, attempts at de-escalation, rationale for restraint, timeframes

Victoria - Chief Psychiatrist's Guideline: Seclusion and Restraint (2013):

• Restraint only when imminent risk of harm
• Mechanical restraint (limb restraints): Authorized by senior clinician, max 4 hours before review
• Chemical restraint: Minimum effective dose, consent where possible, document rationale
• Aboriginal patients: Increased risk of restraint use → explicit bias training for staff [21]

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Remote/Rural Considerations

Pre-Hospital

Ambulance Management:

• Agitation: Paramedics can administer midazolam 5-10mg IM (some states allow droperidol)
• Violence: Police assistance for safety, ambulance will not transport without safety assurances
• Collateral: Paramedics obtain valuable history (living conditions, medications visible, substance paraphernalia)

Police Mental Health Interventions:

• Police can detain under Mental Health Act in most jurisdictions (s297 NSW, s351 Vic)
• Crisis Intervention Training (CIT) for police → better de-escalation, fewer arrests
• Police can transport to ED or designated mental health facility

Resource-Limited Setting

Remote Clinic Modifications:

• Limited staff: Often 1 nurse, no doctor → rely on telehealth for psychiatric consultation
• Limited monitoring: May lack continuous SpO2, ECG → use sedation cautiously (prefer oral over IM if cooperative)
• Limited medications: Stock droperidol, olanzapine wafers, midazolam; haloperidol often unavailable in remote clinics
• Physical restraint: Extremely difficult with 1-2 staff → chemical sedation preferred, involve police if necessary for safety

Modified Workup:

• Point-of-care: Glucose, urine drug screen (if available), vital signs
• Bloods: Send to regional lab (results delayed 24-48 hours) → treat empirically
• Imaging: No CT scanner in remote clinics → clinical decision to retrieve for imaging vs. manage expectantly

Retrieval

RFDS Mental Health Retrieval Criteria:

• Acute psychosis requiring involuntary admission (no local inpatient psychiatry)
• Violence risk too high for local management
• Medical complications (excited delirium, rhabdomyolysis, NMS)
• Substance withdrawal requiring monitoring (alcohol, benzodiazepines)

Pre-Retrieval Stabilization:

• Target sedation: RASS -1 to 0 (calm, cooperative, rousable) — over-sedation risks airway compromise in flight
• Escort: RFDS flight nurse + doctor for high-risk patients; police escort if extreme violence risk
• Equipment: IV access, sedation drugs (midazolam, droperidol), intubation equipment on aircraft
• Handover: Detailed notes (timeline, medications, doses, response, risk assessment, family contacts)

Flight Considerations:

• Altitude: Cabin pressurized to 8,000 feet (2,400m) → hypoxia risk if over-sedated (SpO2 monitoring mandatory)
• Confined space: Cannot manage violent patient in-flight → sedation critical before departure
• Duration: 2-4 hours flight time (remote NT/WA to Darwin/Perth) → redosing may be required
• Cost: AUD $15,000-$30,000 per retrieval (mental health retrievals 10% more expensive than medical due to duration, escort)

Telemedicine

Remote Psychiatric Consultation:

• NT Mental Health Line: 1800 682 288 (24/7 psychiatrist advice for remote clinicians)
• NSW Mental Health Line: 1800 011 511
• QLD Mental Health Access Line: 1300 642 255
• Video consultation: Psychiatrist can conduct real-time MSE, risk assessment, guide medication decisions
• Triage: Telehealth can determine if patient needs retrieval or can be managed locally with outpatient follow-up (reduces retrieval rate 20-30%) [32]

Benefits:

• Immediate specialist advice (vs. hours for RFDS)
• Reduces inappropriate retrievals (cost savings)
• Education for remote clinicians (upskilling)
• Continuity of care (same psychiatrist can follow up via telehealth post-discharge)

Limitations:

• Technology failures (internet outage, poor video quality in remote areas)
• Cannot physically examine patient
• Language barriers (interpreter required for non-English speakers, harder via telehealth)
• Cultural barriers (Aboriginal patients may prefer face-to-face with someone from their community)

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References

Guidelines

1. Australian Bureau of Statistics. National Survey of Mental Health and Wellbeing 2020-21. Canberra: ABS; 2022.
2. McGrath J, Saha S, Chant D, Welham J. Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 2008;30:67-76. PMID: 18480098
3. Saha S, Chant D, Welham J, McGrath J. A systematic review of the prevalence of schizophrenia. PLoS Med. 2005;2(5):e141. PMID: 15916472
4. Häfner H, Maurer K, Löffler W, et al. The influence of age and sex on the onset and early course of schizophrenia. Br J Psychiatry. 1993;162:80-86. PMID: 8425144
5. Aleman A, Kahn RS, Selten JP. Sex differences in the risk of schizophrenia: evidence from meta-analysis. Arch Gen Psychiatry. 2003;60(6):565-571. PMID: 12796219
6. Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry. 2005;62(3):247-253. PMID: 15753237
7. Fazel S, Gulati G, Linsell L, Geddes JR, Grann M. Schizophrenia and violence: systematic review and meta-analysis. PLoS Med. 2009;6(8):e1000120. PMID: 19636355
8. Australian Institute of Health and Welfare. Mental health services in Australia: Aboriginal and Torres Strait Islander people. Canberra: AIHW; 2021.
9. Baxter J, Kingi TK, Tapsell R, Durie M, McGee MA. Prevalence of mental disorders among Māori in Te Rau Hinengaro: The New Zealand Mental Health Survey. Aust N Z J Psychiatry. 2006;40(10):914-923. PMID: 16959018
10. Knott JC, Pleban A, Taylor D, Castle D. Management of mental health patients attending Victorian emergency departments. Aust N Z J Psychiatry. 2007;41(9):759-767. PMID: 17687666

Key Evidence

11. Sara G, Burgess P, Malhi GS, Whiteford H, Hall W. Stimulant and other substance use disorders in schizophrenia: prevalence, correlates and impacts in a population sample. Aust N Z J Psychiatry. 2014;48(11):1036-1047. PMID: 24819936
12. Penttilä M, Jääskeläinen E, Hirvonen N, Isohanni M, Miettunen J. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br J Psychiatry. 2014;205(2):88-94. PMID: 25252316
13. Di Forti M, Quattrone D, Freeman TP, et al. The contribution of cannabis use to variation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study. Lancet Psychiatry. 2019;6(5):427-436. PMID: 30902669
14. Rabinowitz J, Levine SZ, Garibaldi G, Bugarski-Kirola D, Berardo CG, Kapur S. Negative symptoms have greater impact on functioning than positive symptoms in schizophrenia: analysis of CATIE data. Schizophr Res. 2012;137(1-3):147-150. PMID: 22316568
15. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25. PMID: 22353743
16. Wilson MP, Pepper D, Currier GW, Holloman GH Jr, Feifel D. The psychopharmacology of agitation: consensus statement of the American Association for Emergency Psychiatry Project BETA Psychopharmacology Workgroup. West J Emerg Med. 2012;13(1):26-34. PMID: 22303320
17. Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the DORM study. Ann Emerg Med. 2010;56(4):392-401.e1. PMID: 20807310
18. Rund DA, Ewing JD, Mitzel K, Votolato N. The use of intramuscular benzodiazepines and antipsychotic agents in the treatment of acute agitation or violence in the emergency department. J Emerg Med. 2006;31(3):317-324. PMID: 16982376
19. Chan EW, Taylor DM, Knott JC, Phillips GA, Castle DJ, Kong DC. Intravenous droperidol or olanzapine as an adjunct to midazolam for the acutely agitated patient: a multicenter, randomized, double-blind, placebo-controlled clinical trial. Ann Emerg Med. 2013;61(1):72-81. PMID: 23141920
20. Knox DK, Holloman GH Jr. Use and avoidance of seclusion and restraint: consensus statement of the American Association for Emergency Psychiatry Project BETA Seclusion and Restraint Workgroup. West J Emerg Med. 2012;13(1):35-40. PMID: 22461919

Systematic Reviews

21. McGuire TG, Miranda J. New evidence regarding racial and ethnic disparities in mental health: policy implications. Health Aff (Millwood). 2008;27(2):393-403. PMID: 18332495
22. Myles N, Newall HD, Curtis J, Nielssen O, Shiers D, Large M. Tobacco use before, at, and after first-episode psychosis: a systematic meta-analysis. J Clin Psychiatry. 2012;73(4):468-475. PMID: 22579146
23. Dutta R, Murray RM, Hotopf M, Allardyce J, Jones PB, Boydell J. Reassessing the long-term risk of suicide after a first episode of psychosis. Arch Gen Psychiatry. 2010;67(12):1230-1237. PMID: 21135323
24. Tyler KL. Herpes simplex virus infections of the central nervous system: encephalitis and meningitis, including Mollaretʼs. Herpes. 2004;11 Suppl 2:57A-64A. PMID: 15319091
25. Dalmau J, Tüzün E, Wu HY, et al. Paraneoplastic anti-N-methyl-D-aspartate receptor encephalitis associated with ovarian teratoma. Ann Neurol. 2007;61(1):25-36. PMID: 17262855
26. Elbogen EB, Johnson SC. The intricate link between violence and mental disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2009;66(2):152-161. PMID: 19188537
27. Maniglio R. Severe mental illness and criminal victimization: a systematic review. Acta Psychiatr Scand. 2009;119(3):180-191. PMID: 19016668
28. Shawyer F, Mackinnon A, Farhall J, Trauer T, Copolov D. Command hallucinations and violence: implications for detention and treatment. Psychiatry Psychol Law. 2003;10(1):97-107.

Landmark Studies

29. Dudgeon P, Milroy H, Walker R, eds. Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice. 2nd ed. Canberra: Commonwealth of Australia; 2014.
30. Royal Flying Doctor Service. Annual Report 2021-22. Sydney: RFDS; 2022.
31. Australian Institute of Health and Welfare. Mental Health Services in Australia: Restrictive Practices. Canberra: AIHW; 2022.
32. Saurman E, Lyle D, Perkins D, Roberts R. Successful provision of emergency mental health care to rural and remote New South Wales: an evaluation of the Mental Health Emergency Care-Rural Access Program. Aust Health Rev. 2014;38(1):58-64. PMID: 24160675

Additional Evidence

33. Large M, Sharma S, Compton MT, Slade T, Nielssen O. Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Arch Gen Psychiatry. 2011;68(6):555-561. PMID: 21300939
34. Leucht S, Corves C, Arbter D, Engel RR, Li C, Davis JM. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis. Lancet. 2009;373(9657):31-41. PMID: 19058842
35. Kane JM, Correll CU. Pharmacologic treatment of schizophrenia. Dialogues Clin Neurosci. 2010;12(3):345-357. PMID: 20954430
36. Correll CU, Leucht S, Kane JM. Lower risk for tardive dyskinesia associated with second-generation antipsychotics: a systematic review of 1-year studies. Am J Psychiatry. 2004;161(3):414-425. PMID: 14992963
37. Hasan A, Falkai P, Wobrock T, et al. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry. 2012;13(5):318-378. PMID: 22834451
38. National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. NICE Clinical Guideline 178. London: NICE; 2014.
39. Galletly C, Castle D, Dark F, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Aust N Z J Psychiatry. 2016;50(5):410-472. PMID: 27106681
40. Alvarez-Jimenez M, Parker AG, Hetrick SE, McGorry PD, Gleeson JF. Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis. Schizophr Bull. 2011;37(3):619-630. PMID: 19900962
41. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2011;(6):CD004718. PMID: 21678345
42. The Australian Clinical Guidelines for Early Psychosis. 2nd ed. Orygen; 2016.