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Chapter 225: Assessment and Management of Psychosis

Anand K. Pandurangi

INTRODUCTION

Key Clinical Questions

  • image What is psychosis?

  • image What are the various psychotic disorders?

  • image How are psychotic disorders diagnosed?

  • image How is psychosis treated in the acute hospital setting?

  • image What are the complications of psychosis?

  • image What is an optimal discharge plan for patients who are recovering from psychosis?

New-onset psychosis and recurring psychosis identified during the course of assessment and treatment of medical disorders, require immediate intervention. 0.5% to 2.5% of all (nonpsychiatric) hospitalized patients have a pre-existing chronic psychosis and 5% to 25% of all referrals for psychiatric consultation in a hospital setting are for a psychotic disorder. New-onset psychoses may be secondary to a general medical condition, iatrogenic or functional in nature. Initiation of treatment for new cases and continuation (or resumption) of treatment for pre-existing psychosis is of paramount importance. Psychosis in children and adolescents, postpartum period and in the elderly requires special attention to dosing and adverse effects. Neglecting or undertreating the psychosis will likely lead to behavioral and medical complications. Psychosis can quickly erupt into a crisis, affecting safety, the management of the medical disorder(s) and altering hospital course and outcome. The presence of comorbid psychiatric conditions, especially if unrecognized or undertreated often increases the length of stay and cost of care. Key point in the management of psychosis is outlined in Table 225-1.

TABLE 225-1Key Points to Managing Psychosis
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TABLE 225-1 Key Points to Managing Psychosis

  • Psychosis is a sustained mental state of impaired contact with reality.

  • Psychosis is manifested with one or more of the following: hallucinations, delusions, disordered communication, and unusual behaviors.

  • Short-lasting functional psychotic disorders include brief psychotic disorder and schizophreniform disorder.

  • Chronic or recurrent functional psychotic disorders include schizophrenia, schizoaffective disorder, delusion disorder, and severe mood disorders.

  • Substance abuse may cause psychosis.

  • Endocrine, immunologic, metabolic, neoplastic, and other general medical disorders as well as substance abuse and select medications may cause or contribute to psychosis.

  • Psychosis may be seen as part of dementia or delirium, or in association with a developmental disorder such as autism or intellectual disability (mental retardation).

  • Sensory impairment may cause or contribute to a paranoid psychosis in the elderly patient.

  • Assessment includes history of the psychotic symptoms including time course, medical review of systems, physical and mental status examinations, and laboratory tests as needed.

  • Diagnosis may be made by applying the DSM-5 criteria to the above information.

  • Antipsychotic medications are essential to control the psychosis.

  • A safe and supportive environment is necessary.

  • Florid psychosis persistent for several days is best treated on a psychiatric unit, when feasible.

  • Psychosis may take 3-14 d to resolve and sometimes longer.

  • Education of the patient and significant others on compliance, side effects, and signs of relapse is a key ingredient of a safe discharge plan.

  • Patients need follow-up care within 1-2 wk of discharge.

DEFINITIONS AND TERMINOLOGY

The term psychosis...

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