Critical Alerts

• Always rule out organic causes first: Up to 10% of "psychiatric" presentations have medical etiology
• Delirium mimics psychosis: Fluctuating consciousness = NOT primary psychosis
• Medical clearance is essential: Check glucose, electrolytes, tox screen, vital signs
• Never assume "known psychiatric patient": New organic cause may be present
• Excited delirium syndrome: Can lead to sudden death - requires immediate intervention
• Serotonin syndrome and NMS: Life-threatening medication reactions

Key Diagnostics

Emergency Treatments

Overview

Acute psychosis is a syndrome characterized by a break from reality, manifesting as delusions, hallucinations, disorganized speech, or grossly disorganized/catatonic behavior. In the emergency department, the priority is ensuring safety, ruling out life-threatening organic causes, and providing appropriate pharmacological intervention.

Classification

By Etiology:

By Presentation:

• First-episode psychosis: Initial presentation; requires thorough medical workup
• Recurrent episode in known condition: Still requires medical screen
• Acute-on-chronic: Exacerbation of baseline; medication non-adherence common

Epidemiology

• Lifetime risk of psychotic disorder: 3% of population
• Schizophrenia prevalence: 1% worldwide
• Age of onset: Males 15-25 years; females 25-35 years
• ED presentations: 10-15% of psychiatric emergencies involve psychosis
• Substance-induced: 25-50% of psychosis presentations in urban EDs

Etiology

Primary Psychiatric Disorders:

• Schizophrenia (most common chronic cause)
• Schizoaffective disorder
• Brief psychotic disorder (<1 month)
• Schizophreniform (1-6 months)
• Bipolar disorder with psychotic features
• Major depression with psychotic features
• Delusional disorder

Substance-Related:

Medical Causes (MUST Exclude):

Indicators of Medical/Organic Cause

Psychiatric Emergencies

Medical Mimics of Psychosis

Psychiatric Differential

Immediate Safety and Stabilization

1. Ensure scene safety for staff and patient
2. De-escalation techniques
3. Physical restraints only as last resort
4. Rapid assessment of dangerous behaviors

Medical Clearance Algorithm

All Patients:

• Fingerstick glucose
• Vital signs (T, HR, BP, RR, O2 sat)
• Urine drug screen
• Basic metabolic panel
• Mental status examination

First Episode Psychosis or High Suspicion for Organic:

Consider in Young Patients with Unusual Presentation:

• Anti-NMDA receptor antibodies
• Autoimmune encephalitis panel
• MRI brain

Clinical Decision Rules

Organic vs Primary Psychiatric Psychosis:

Admission Criteria

Psychiatric Admission:

• First episode psychosis requiring stabilization
• Danger to self (suicidal ideation/behavior)
• Danger to others (homicidal ideation/behavior)
• Unable to care for self due to psychosis
• Medication non-adherence requiring supervised treatment
• Failed outpatient management

Medical Admission:

• Identified medical cause requiring treatment
• Uncertain etiology requiring further workup
• NMS, serotonin syndrome, excited delirium
• Delirium requiring ongoing evaluation

Discharge Criteria

• Medical causes excluded or treated
• No imminent danger to self or others
• Able to care for basic needs
• Support system in place
• Outpatient follow-up arranged
• Medication plan established

Involuntary Commitment

• Laws vary by jurisdiction
• Generally requires:
  • Mental illness present
  • Danger to self or others OR unable to care for self
  • Less restrictive alternatives not appropriate
• Document clearly the specific criteria met

Follow-Up Recommendations

Condition Explanation (For Families)

• "Your family member is experiencing psychosis, which means their brain is having difficulty distinguishing what's real from what isn't."
• "This can be caused by mental illness, substances, or physical medical conditions."
• "With proper treatment, many people with psychosis can lead stable lives."

Medication Education

• Explain purpose of medications
• Common side effects to expect
• Importance of adherence
• Warning signs requiring return

Safety Planning

• Remove access to weapons
• Supervise medications
• Have crisis numbers available
• Develop a crisis plan

Warning Signs Requiring Return

• Worsening symptoms
• Refusal to eat or drink
• Medication side effects (stiffness, fever, repetitive movements)
• Suicidal or aggressive thoughts
• Inability to care for self

Adolescents

• First episode often presents in adolescence
• Differentiate from substance use
• May present with prodromal symptoms
• Early intervention programs improve outcomes
• Involve family when possible

Elderly

• Always assume organic cause until proven otherwise
• Delirium extremely common
• Lower doses of all medications
• UTI is common trigger for altered mental status
• Anticholinergic effects more pronounced
• Increased sensitivity to antipsychotics

Pregnant Patients

• Teratogenicity considerations
• Haloperidol has longest safety record
• Olanzapine, risperidone relatively safe
• Avoid valproate, carbamazepine
• Involve obstetrics
• Untreated psychosis risks outweigh medication risks

Patients with Intellectual Disability

• May have difficulty communicating symptoms
• Baseline behavior important from caregivers
• Lower threshold for medical workup
• Adjust communication style
• Consider nonverbal signs of distress

Substance Use Disorder Comorbidity

• Extremely common (50% of schizophrenia patients)
• Complicates treatment
• May need dual diagnosis program
• Risk of withdrawal syndromes

Performance Indicators

Documentation Requirements

• Safety assessment (SI/HI documented)
• Medical clearance workup and results
• Mental status examination
• De-escalation attempts
• Medication administration times and effects
• Restraint justification if used
• Capacity assessment
• Disposition decision and rationale
• Follow-up arrangements

Diagnostic Pearls

• "All psychosis is organic until proven otherwise": Always medical workup
• Fluctuating consciousness = delirium, not psychosis: Key distinction
• Visual hallucinations suggest organic cause: Be suspicious
• First episode over 40 = medical etiology likely: Extensive workup
• "Drug screen negative" doesn't exclude substance use: Synthetic drugs may not be detected
• Anti-NMDA encephalitis: Think of in young women with psychiatric + movement signs

Treatment Pearls

• De-escalation first: Often effective and safer
• Offer oral before IM: Less traumatic, builds rapport
• Benzodiazepines if unsure of etiology: Safe for organic causes
• Avoid IM olanzapine + IM benzodiazepine together: Cardiorespiratory depression
• 5-10-15-20 rule: Reassess effect every 15-20 minutes before re-dosing
• "Start low, go slow" in elderly: Paradoxical worsening possible

Disposition Pearls

• Psychiatric hold criteria vary by state: Know your local laws
• Document danger clearly: Specific behaviors and statements
• Family involvement improves outcomes: Engage when appropriate
• Outpatient follow-up is essential: Arrange before discharge
• Substance-induced psychosis: Resolves with abstinence but may unmask primary disorder