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Chapter 226. Assessment and Management of Psychosis

Anand K. Pandurangi, MBBS, MD

  1. What is psychosis?

  2. What are the various psychotic disorders?

  3. How are psychotic disorders diagnosed?

  4. How is psychosis treated in the acute hospital setting?

  5. What are the complications of psychosis?

  6. 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. 0.5–2.5% of all (nonpsychiatric) hospitalized patients have a preexisting chronic psychosis and 5–25% of all referrals for psychiatric consultation are for a psychotic disorder. New-onset psychoses may be secondary to a general medical condition, iatrogenic or functional in nature (Table 226-1). Initiation of treatment for new cases and continuation (or resumption) of treatment for preexisting psychosis is of paramount importance. Neglecting or under treating the psychosis will likely lead to behavioral and medical complications. Psychosis can quickly erupt into a crisis, affecting the management of the medical disorder(s) and altering their outcome. The presence of comorbid psychiatric conditions, especially if unrecognized or under treated often increases the length of stay and cost of care.

Table 226-1 Key Points
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Table 226-1 Key Points
  • 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 may lead to the manifestation of psychosis.
  • Psychosis may be seen as part of dementia or delirium, or in association with a developmental disorder such as autism or mental retardation.
  • 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 is made by applying the DSM-IV 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 days 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 one to two weeks of discharge.

The term psychosis was first used in the mid-19th century to denote an abnormal state of mind, and typically refers to a loss of touch with reality. In 1896, Emil Kraeplin dichotomized the functional psychoses into dementia precox and manic-depressive illness to denote a chronic deteriorating cognitive disorder and an intermittent mood disorder, respectively. In 1911, Eugen Bleuler renamed the former condition as schizophrenia. This dichotomization does not cover all psychotic disorders, and various other psychotic disorders have been described. These include stress-induced reactive ...

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