National University of Rwanda Family and Community Medicine

Acute psychosis
KABERA Ren,MD PGY IV Resident Family and Community Medicine National University of Rwanda

Plan
Definition Signs and Symptoms Mechanisms Etiology Diagnosis Treatment

Definition
Loss of contact with reality, a psychiatric disorder or mania that is marked by delusions, hallucinations, incoherence, and distorted perceptions of reality.

Signs and symptoms

Delusions are erroneous beliefs that: Involve a misinterpretation of perceptions Are clearly implausible Are often persecutory, religious, or somatic in nature Hallucinations Sensory experiences that exist only in the mind of the patient Can involve any sense; auditory and visual are most common Disorganized speech Loose associations Neologisms Perseverations Poverty of content Word salad

Signs and symptoms

Disorganized or catatonic behavior Unable to perform goal-directed behavior Unaware of the environment Negative symptoms Flattened affect Poverty of speech Unable to maintain goal-directed activities

Signs and symptoms

Features suggesting an organic etiology Sudden onset, >40 years old, fluctuating course, Headaches, Speech difficulties, Delusions are disorganized, Incoherent speech,

Signs and Symptoms

Confusion Loss of consciousness Focal neurologic symptoms Abnormal vital signs Disorientation Psychomotor retardation Visual hallucinations Global impairment of attention and cognitive function Labile affect Social immodesty

Mechanisms
A description of behavior that does not imply a specific cause or diagnosis in general The psychosis may be secondary to functional (psychiatric) or organic (medical) causes Medical psychoses are generally secondary to systemic or neurologic diseases, or neuroactive medications Neurodevelopmental abnormalities in the dopaminergic and serotonergic systems are implicated in functional psychosis

Etiology
Organic Central nervous system: Encephalopathy, Seizure, Head injury, Neoplasms, Migraine,(stroke(CVA) Genetics: Huntington's chorea Metabolic: Intoxication or withdrawal, Hypercarbia, Hypoglycemia, Hypoxia, Poisoning ,Electrolyte imbalance

Etiology
Endocrine: Addison's disease, Thyroid dysfunction, Parathyroid dysfunction Others: Autoimmune disorders, Hepatic encephalopathy ,Renal failure

Etiology
Pharmacologic Psychoactive agents: Benzodiazepines Chlordiazepoxide Antidepressants Antiepileptics Antibiotics: Isoniazid, Rifampin Cardiovascular agents: Captopril Digoxin Methyldopa Procainamide Propranolol Reserpine Drugs of abuse: Alcohol Amphetamines Cocaine Opioids Hallucinogens Others: Steroids Heavy metals Antihistamines Cimetidine Disulfiram

Etiology
Functional Brief psychotic disorder Usually secondary to acute emotional stress Schizophreniform disorder Symptoms present 1-6 months Schizophrenia Mood disorder with psychotic features or schizoaffective disorder

Diagnosis
History and physical examination Laboratory Routine "screening labs" not helpful Specific studies should be guided by the suspected underlying etiologies Serum glucose Toxicologic screen Serum electrolytes Urinalysis

Diagnosis
Imaging/Special Tests Head CT scan indicated in patients at risk for a neurologic etiology Lumbar puncture

Treatment
Medications Antipsychotics Droperidol: 2.5-5.0 mg i.v. or i.m. Haloperidol: 2-5 mg i.v. or i.m. or PO; 0.5-2.0 mg for elderly Risperidone: 1-2 mg PO Benzodiazepines Lorazepam 1.0-2.0 mg i.v. or i.m. or PO Treatment of medication side effects Benztropine: 2 mg i.m. or i.v. Dantrolene: 1 mg/kg i.v. repeated to symptom resolution or total of 10 mg/kg Diphenhydramine: 50 mg i.v., i.m., or PO

The end

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