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Psychosis is a condition defined as a loss of contact with reality. By definition, it is a disruption in thinking, accompanied by delusions or hallucinations.
Psychotic symptoms can increase the risk of a patient harming himself or herself, others, or of being unable to meet basic needs.
Features of Psychosis
DELUSIONS: strong false beliefs not typical of a person's cultural or religious background. They can be:
- Persecutory (e.g., convinced someone is following them or harassing them).
- Grandiose (e.g., believing one is an important person necessary for world peace.)
- Erotomanic (e.g., believing a famous person is in love with them).
- Somatic (e.g., believing bugs come out of one's nose at night).
- Delusions of reference (e.g., believing a conversation in a movie is about them.)
- Delusions of control (e.g., believing one’s thoughts and actions are under the control of aliens.)
HALLUCINATIONS: wakeful sensory experiences that do not actually occur. Auditory hallucinations (e.g., hearing voices) are the most common, followed by visual, tactile, and taste hallucinations.
Illusions are different, which are distortions or misinterpretations of real sensory stimuli.
THOUGHT DISORGANIZATION: patterns of speech that can also be present in delirium or other cognitive impairments.
- Alogia/"poverty" of content: minimal if any information via speech.
- Thought blocking: sudden loss of one's train of thought, with abrupt interruptions in speech.
- Loose associations: sequences of ideas that are not closely related.
- Tangent speech: answers that diverge from the topic being asked about.
- Circumstantiality: when the content eventually returns to the original topic.
- Clanging: speaking in a rhyming or phonetically connected cadence. For example, "I'm in the wrong religion long division song provision."
- Word salad: real words linked together incoherently, ending up nonsense: nonsensical content.
- Perseveration: persistently repeating words or ideas, even after introducing another interview topic.
AGITATION or AGGRESSION: agitation is an acute state of anxiety, emotional swing, and hyperactivity. Not exclusive to psychosis, it is relevant in that it can lead to bodily harm to one's self or others. Body language and voice intonations can offer warnings of agitation or likely aggression.
In the field, safety comes first, for you and your team, by performing an adequate scene-size-up and make sure your scene is safe before arrival.
In agitated patients, every effort should be made to calm the patient and de-escalate tensions. Keep a safe distance, ask questions and speak in a calm, reassuring manner, and encourage the patient to talk. Explain everything and answer questions honestly. Don't "play along" with a patient's hallucinations or delusions. Use eye contact, slow movement, and treat the patient with respect and reduce stressful stimuli. (Avoid excessive, direct eye contact, especially staring, which can be interpreted as an aggressive act.)
Acknowledge that you are listening and limit the physical touch in agitated patients. When assessing your patient's psychiatric health, you're trying to assess the ability of the patient to make logical decisions. Do not leave the patient alone unless your scene becomes unsafe.
Psychosis due to Psychiatric vs Medical Conditions
Psychiatric (non-organic) psychotic episodes are insidious in onset, have a history going back to younger ages )from teens-thirties), and often involve auditory hallucinations.
Medical psychotic episodes have an acute onset, a history starting later (forties), and typically feature non-auditory hallucinations (visual, tactile, olfactory).
In the field, your initial assessment will follow an algorithm to differentiate psychosis related to psychiatric from that of a medical condition:
To conclude the psychosis is psychiatric in origin,
- rule out diminished consciousness and neurologic disorders that have an acute focal neurologic deficit, then
- check your patient for attention span and cognitive ability.
If there is no diminished consciousness nor any neurologic findings, but there are problems with attention, short-term memory, and cognitive ability, this is confusion/delirium.
If there is no diminished consciousness nor any neurologic findings, nor any problems with attention, short-term memory, and cognitive ability, this is a thought disorder--psychiatric.
Primary Psychiatric Disorders
SCHIZOPHRENIA: the presence of psychotic symptoms for significant portions of time of each month, for at least 6 months, with a decline in functioning.
Schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, and schizotypalpersonality disorder are each a variation of schizophrenia, but with incomplete criteria met to establish the official schizophrenia diagnosis.
MAJOR DEPRESSIVE DISORDER WITH PSYCHOTIC FEATURES: depression for a 2-week period along with distress or functional impairment.
BIPOLAR DISORDER WITH PSYCHOTIC FEATURES: alternating depression + mania episodes for at least one week, present most of the day, nearly every day, severe enough to cause social impairment, occupational difficulties, require hospitalization to prevent harm to self or others or associated with psychotic features.
MEDICATION-INDUCED PSYCHOSIS: many prescription medications, as well as illicit substances, can induce transient psychotic symptoms.
MEDICAL OR NEUROLOGICAL-INDUCED PSYCHOSIS:
- Delirium: an acute mental disturbance characterized by problems of attention, confusion, and disorientation, often sudden in onset. Frequent causes of delirium include
- fluid or electrolyte abnormalities,
- infections, and
- medications, substance intoxication or withdrawal
- Hepatic and renal disorders:
- hepatic encephalopathy, and
- uremic encephalopathy.
- Infectious disease:
- tertiary syphilis,
- herpes simplex encephalitis, or
- Lyme disease.
- Inflammatory or demyelinating disorders:
- anti-NMDA receptor encephalitis,
- systemic lupus erythematosus,
- multiple sclerosis, and
- Neurodegenerative disorders:
- Alzheimer disease,
- dementia with Lewy bodies,
- Parkinson’s disease,
- Huntington’s disease.
- head trauma/traumatic brain injury,
- space-occupying lesions (tumors, cysts),
- seizure disorders,
- Vitamin deficiency: vitamin B12 deficiency.
Acute Psychosis in Children
Because acute psychosis from psychiatric illness is uncommon, any new onset of psychosis in a child or adolescent should make you consider other medical etiologies before declaring it psychiatric.
HYPOGLYCEMIA is a rare, but important cause of psychosis and hallucinations. All alterations in mental status require capillary glucose testing.
CEREBRAL HYPOXIA is inadequate brain oxygenation which can cause mental status changes with combative behavior.
- Hypoxemia from pulmonary insufficiency,
- insufficient oxygen-carrying capacity of the blood from severe anemia, or
- inadequate brain perfusion from cardiac disease...
...can result in encephalopathy with psychotic features.
Cerebral hypoxia is a life-threatening emergency that requires quick identification of the cause of cerebral hypoxia and intervening rapidly to restore oxygenation.
Children are at risk for all of the causes of acquired psychosis as adults--drugs, toxicities, metabolic or electrolyte abnormalities, and even psychiatric illness.
Management of Suicide Risk
In the field, your biggest challenge* with behavioral abnormalities in psychosis will be in preventing suicide.
*aside from addressing the medical complications arising from the suicide attempt.
ASSESSMENT FOR SUICIDE RISK:
- Teenagers have a greater risk of suicide attempt related to the general hormonal psychiatric chaos of adolescence.
- Geriatric patients experiencing psychiatric health concerns are also at a higher risk for depression and suicide.
- Suicide risk increases with age; however, young adults attempt suicide more often than older adults.
- Females attempt suicide nearly twice as often as males, but males complete suicide three times more often, which may be related to males choosing more lethal means (e.g., firearms).
- DEPRESSION: psychiatric illness is a strong predictor of suicide.
>90% who attempt suicide have a psychiatric disorder, and 95% of those who successfully commit suicide have a psychiatric diagnosis. The severity of the psychiatric illness correlates with the risk of suicide.
The psychiatric disorders most commonly associated with suicide include:
- bipolar disorder,
- alcoholism or other substance abuse, and
The strongest single factor predictive of suicide is a prior history of attempted suicide.
Important questions for the responder include:
- How does the patient feel?
- Are there suicidal tendencies?
- Is the patient threat to self or others?
- Is there a medical problem?
- Is there trauma involved?
- Have there been Interventions?