Acute Psychosis (ALS)

Dr. Katz's Assessment Of This Case

Acute psychosis is a true emergency and can present with several different possible
presentations. These patients vary from disoriented and bizarre, to being extremely
aggressive. It is typically difficult to distinguish the underlying cause of a patient's
psychotic symptoms.  Careful history taking can often uncover important clinical clues.
Crew safety is always of paramount importance. Since these patients are often poor
historians, it is dependent upon you to use your thorough assessment skills to collect
any evidence you find during the scene survey, and interview bystanders to help piece
together the reasons behind your patient's symptoms. 
Remember, patients that are exhibiting violent or bizarre behavior can create an
immediate threat to themselves, the crew, or bystanders. They should be safely and
effectively restrained, if necessary, to prevent harm to self or others. Also, law
enforcement should be called when necessary.

In Case Of Psychiatric Emergency

In a scenario involving a patient with a possible psychiatric emergency, it is critical that
you stabilize the patient to the best of your ability, assess if the patient is a threat to
himself or others, and evaluate any underlying medical condition
(i.e. hypoglycemia or illicit drug use).  At the same time, always consider the safety of
the patient and the crew. Respect the patient's dignity, identify and treat identifiable
causes (i.e. hypoglycemia), use restraints (i.e. physical or chemical) as needed, and
perform and document your continuous monitoring of the patient.

Delusions
Delusions are fixed beliefs that are not shared by others of a person's culture or
background, and that cannot be changed by a reasonable argument. Delusions are false
beliefs.  These misrepresentations may be based upon:

 Being wrongly persecuted or blamed

 Blaming another person for something  that has happened

 Somatic (i.e. something related to their body)

 Religious beliefs

Hallucinations
Hallucinations are false perceptions; a sense perception not based on objective reality.
These misperceptions originate from sources that are not actually present and may
include:
  Auditory (i.e. hearing voices) - most common form of hallucination

 Visual (i.e. seeing people or things)

 Olfactory (i.e. smelling something)

 Gustatory (i.e. tasting something) 

 Tactile (i.e. sensing a touch from something or someone)

Acute Psychosis
Acute psychosis patients typically present to emergency care providers with strange or
bizarre behavior that includes:

 Unusual mannerism or behavior (i.e. apathy, fear, or rage)

 Unusual posturing

 Responding to their hallucinations (i.e. talking to themselves)

 False and delusional beliefs

 Confusion between reality and fiction

 Excessive or deficient psychomotor activity (i.e. extreme restlessness to

stuporous)

What Causes Acute Psychosis?

 Schizophrenia

 Bipolar disorder

 Major  Depression  with psychotic features

 Alzheimer's disease

 Delirium

 Ingestion (i.e. medications, alcohol, illicit drugs, withdrawal)

 Delirium tremens
Schizophrenia
Schizophrenia is a common worldwide mental health disorder. The disorder affects
approximately 1% of the total world population, often presenting with delusions, 
hallucinations, disorganized speech, and flat affect. Auditory hallucinations (i.e. hearing
voices) are the most common type of hallucination. 2
Schizophrenia patients often seek medical attention due to worsening psychosis (i.e.
non-compliance with medications, stress, suicidal, or aggressive behavior) and
extrapyramidal symptoms (i.e. akathisia, dystonia, and dyskinesia). These patients
should be treated with caution, as they can be prone to violent behavior.
Schizophrenia is more common in men than women, with patients commonly being first
diagnosed in their twenties. Substance abuse is also commonly seen in this patient
population.

Bipolar Disorder And Alzheimer's Disease

Bipolar disorder is behavior fluctuating between the “poles” of depression and mania.
Manic episodes are characterized by abnormally exaggerated happiness, joy, or
euphoria with hyperactivity, insomnia, and grandiose ideas. 80% of untreated patients
with manic symptoms will develop symptoms of psychosis. 3
Alzheimer’s disease  – up to 40% of patients with Alzheimer’s can have psychotic
symptoms.

Delirium
Delirium is the acute confusional state characterized by global impairment of
thinking, perception, judgment, and memory. Unlike dementia (i.e. gradual
deterioration of cognitive abilities), delirium presents with acute onset. In delirium, the
patient's consciousness becomes cloudy with extreme sensory misperceptions of reality.
Common causes of delirium include:

 Intoxicants (i.e. alcohol)

 Withdrawal syndromes

 Infections

 Trauma (i.e. subdural bleed)

  Seizures

 Endocrine (i.e. hyperglycemia, hypoglycemia)

 Inflammation

 Shock

 Organ failure (i.e. liver failure, renal failure)

 Cancer
Patients with delirium may transition from being calm and cooperative, to being
extremely agitated within a short period of time. These patients may also manifest
significant changes in psychomotor activity, ranging from extreme restlessness to
extreme decreased activity and alertness.

Alcohol Related Psychosis

Psychosis from alcohol related causes can be due to any of the following: 

 Long-term alcohol abuse

 Thiamine deficiency (i.e. malnutrition, excessive vomiting)

 Alcohol withdrawal

Delirium Tremens - DTs

Delirium tremens (DTs) are most dangerous and potentially life-threatening syndrome
in alcohol withdrawal patients. DTs will typically present within 48-72 hours after a
person stops consuming alcohol, but may be delayed up to 10 days in some cases.
While only 1 in 20 alcohol withdrawal patients present with delirium tremens
(DTs), mortality can be as high as 15%, making early recognition and treatment
essential.
Symptoms of patients with delirium tremens include:

 Confusion

 Tremors

 Restlessness (extreme)

 Fever

 Diaphoresis

 Hallucinations

 Hypotension
When The Crew Arrives
As soon as the crew arrives on the scene, the lead medic immediately assesses scene
safety, calls for a thorough scene survey and an interview with the patient's wife.

Scene Safety
It is critically important in a scenario when you are treating a patient with a psychiatric
emergency, to approach in a calm, non-threatening manner. Use appropriate personal
protective equipment.  Make sure the scene is safe for your crew.  Never hesitate to call
law enforcement if you sense your crew may be in danger.  Make sure your patient is
also not a threat to himself.  Establish the ABCs, and place the patient on oxygen. 
If possible, take a history, full set of vital signs and a thorough physical exam. If
paramedic care is available, establish an IV and get a blood sugar, and administer
medications as needed for chemical restraint (i.e. benzodiazepines, diphenhydramine,
haloperidol) as per you local protocol.

ABC's
Airway:  Airway is clear without signs of obstruction. 
Breathing:  Breathing is unlabored, with a rate of 24, oxygen is immediately applied.
Circulation:  Pulses are present and regular. Heart rate is 120.
Immediate Treatment

 Personal protective equipment

 Scene safety/Prevention of injury

 ABCs/Oxygen

 History

 Vital signs

 Physical examination

 Paramedic care: IV, blood sugar evaluation, administration of medications

(i.e. benzodiazepines, diphenhydramine, haloperidol) as appropriate.
As soon as the ABC's are completed, our lead medic initiates his SAMPLE history and
performs a head-to-toe exam

Patient History
Appropriately, the crew on scene maximizes their history-taking skills by acquiring as
much information as possible from the patient's wife and scene survey. When
interviewed, the patient's wife tells the crew that the patient has been acting very
strange today.  When asked if there was any prior head injury, or possible trauma, the
wife also noted that the patient fell down and hit his head two days ago. He did not lose
consciousness.
The wife tells the crew that the patient has not been depressed, or made any suicidal or
homicidal statements. She does mention that he has anxiety and paranoid
schizophrenia and that he takes medication for it.  She does not know if he has been
taking his medication as prescribed.  It's always a good idea to ask how the patient's
present mental status compares with his or her baseline. Our patient lives with his
wife.  As soon as the interview has been conducted, our medic begins a thorough scene
survey

Restraints
Patients that are exhibiting violent and/or bizarre behavior who create an immediate
threat to self, crew, or bystanders should be safely and effectively restrained to prevent
harm to self or others. Observe for changes in behavior and avoid provoking the
patient. It is also important to use extreme caution when caring for the patient when
law enforcement has employed "non-lethal" efforts (i.e. pepper spray, Taser, etc.). As
always, follow your local protocols and the advice of your Medical Director.

Scene Survey
Our scene survey in this scenario reveals nothing out of the ordinary. When called to
respond to a scene in a home, the scene survey in a psychiatric crisis patient should
always include looking for any safety hazards, or living conditions that may provide
clues like drug paraphernalia, illegal substances, or alcohol containers.  All of these
items, if found, need to be relayed to either law enforcement and/or hospital personnel.

Tips
Trauma, Thermal, Tumor:  Always consider trauma. Patients do not always tell us about
recent injuries. Look for signs of bruising or injury that may explain altered mental
status. Look for signs of head trauma. Is there any bruising present? Is there bruising
around the eyes or behind the ears that may indicate a basilar skull fracture? Does the
patient complain of a headache? Is there an elevated temperature that may explain the
patient's confusion? Is there any reason to suspect a heat-related emergency?
Infection:  Examples include meningitis and encephalitis. 
Intracerebral vascular disorders  would include subarachnoid hemorrhage. Infection
and sepsis should be considered for patients with altered mental status. Temperature is
a very important vital sign to obtain, for any patient with altered mental status. The
patient with altered mental status and a fever is much more likely to have an infection
as the reason for their altered mental status. Meningitis and encephalitis will often be
accompanied by altered mental status. 
Poisoning and Psychiatric causes:  How about ingestions? Is there a suspicion of intentional
or unintentional overdose of medications or drugs? Does the scene survey reveal any
open medicine containers or chemicals that may have been accessed by the patient?  Is
our patient depressed, suicidal or have a history of psychiatric illness? Psychiatric
reasons for altered mental status should always be considered, but never something to
assume in the pre-hospital environment. Always look for other possible causes and
avoid making assumptions. 
Seizures:  Seizures or intracerebral bleeding can cause altered mental status. Ask
caregivers about history of seizures or other history. Seizures are defined as a
temporary alteration in behavior or function due to massive electrical discharge of
groups of neurons in the brain. Seizures are typically classified as either generalized or
partial. A grand mal seizure is a generalized seizure typically characterized by jerking
movements of the extremities and loss of consciousness. Respirations may become
irregular and the patient's facial muscles may twitch. Incontinence is also common.
Grand mal seizures are often associated with a postictal phase. During the postictal
phase, shaking has stopped and patients are often confused and fatigued. Patients in a
postictal phase may resemble a patient with a stroke, as speech may be slurred and
patients often appear confused.

Treatment Considerations
 Respect patient dignity

 Safety of patient and crew

 Identify and treat causes as appropriate (i.e. hypoglycemia, hypoxia, poisoning,

etc.)

 Restraint – physical and/ or chemical as appropriate

 Continuous monitoring of patient (i.e. airway deterioration, emesis, injury)

 Justify and thoroughly document need for restraints

Causes Of Altered Mental Status

When performing a history and physical exam of the psychiatric emergency patient,
consider the possible causes of altered mental status with the mnemonic TIPS AEIOU.
TIPS AEIOU

 T rauma,  T hermal,  T umor

 I nfection (Meningitis, Encephalitis),  I ntracerebral vascular disorders

(i.e. subarachnoid hemorrhage)

 P oisoning,  P sychogenic

 S eizure,  S hunt malfunction

 A lcohol,  A cid-base disorders,  A buse

 E ncephalopathy (Hypertensive, Reye's syndrome, septic shock,

HIV),  E lectrolytes

 I nsulin (Hypoglycemia, Hyperglycemia)

 O piates and other drugs of abuse

 U remia (Renal failure)

AEIOU
Alcohol, Acid-base disorders, Abuse:  Alcohol in any form (i.e. ethanol, ethylene glycol,
isopropyl alcohol, or methanol) could be a possibility for a patient’s altered mental
status. Always ask about alcohol and look for clues that may suggest alcohol
intoxication such as scene survey findings and the odor of alcohol on the breath.
Remember, patients with diabetic ketoacidosis from hyperglycemia can also have a
breath odor similar to alcohol.
Encephalopathy:  Encephalopathy can be caused by hypertension, Reye’s
syndrome, septic shock, and HIV. 
Electrolyte abnormalities  like high or low sodium levels or high or low glucose levels can
cause altered mental status.
Insulin :  Insulin-related causes of altered mental status include hypoglycemia and
hyperglycemia. One of the most common reasons for altered mental status is
hypoglycemia. This typically occurs in the insulin-dependent diabetic who has either not
eaten enough or may have an underlying infection. Hypoglycemia is easily diagnosed
with a blood glucose check and is easily treated by administering oral glucose or IV
dextrose. Metabolic abnormalities, such as hyperglycemia in the poorly controlled or the
undiagnosed new-onset diabetic, will often be accompanied by altered mental status. 
Opiates:  Opiates and other drugs of abuse are notorious for causing altered mental
status.  Always investigate and ask about the possibility of drug abuse. Track marks are
an important clue that may indicate IV drug abuse.
Uremia :  Caused by renal failure.

Definitions
Delusions:  False beliefs that cannot be argued, regardless of facts.
Hallucination :  Profound distortion in a person's perception of reality. Person may sense
(i.e. see, hear, smell, taste, feel) something that is not actually present.
Extrapyramidal  symptoms :  Akathisia, dystonia, and dyskinesia.
Akathisia:  Feeling of extreme restlessness and desire to move.
Dystonia:  Uncoordinated, involuntary muscle contractions.
Dyskinesia:  Involuntary muscle movements (i.e. tongue, lips, face, trunk, extremities).

Preliminary Diagnosis
Based on our clues of our patient exhibiting signs of increased agitation and acute
behavioral changes, in the context of a history of schizophrenia, recent head trauma,
and the presence of fever, our concerns include infection, intracerebral bleeding,
acute psychosis from schizophrenia, medication side effects, or other possible causes.

Pearls Of Wisdom
Do not make assumptions about a psychiatric emergency. There are many organic and
functional causes that may precipitate a patient's bizarre or unusual behavior. Do not
forget blood sugar and temperature checks, as these can sometimes be very helpful in
determining an etiology of a patient's symptoms.

Do not assume that alcohol and/or drug abuse is not possible because the patient has a
psychiatric history. Be thorough, perform a thorough history and physical exam, be
methodical, and avoid making assumptions.

Glasgow Coma Scale

Glasgow Coma Scale  is standardized method using a scale from 3-15 to assess a
patient's level of consciousness by evaluating best eye opening, verbal, and motor
responses. This scale should be done on all patients with altered mental status and
repeat evaluations are useful. Repeat evaluations should be recorded with the times
that these were performed. This is helpful to the personnel at the hospital, and is also
extremely helpful if the case is ever later reviewed in a court of law.
                                             Glasgow Coma Scale
     Eye Opening                                                                   Verbal Response  
    Spontaneous           4                                                      Oriented and
converses        5
    To verbal command 3                                                      Disoriented and
converses    4
    To pain                   2                                                      Inappropriate words        
3
    No response            1                                                      Incomprehensible sounds
2  
                                                                                          No
response                       1    
Motor Response    
Obeys verbal commands                                                    6
Localizes pain                                                                   5
Withdraws from pain (flexion)                                            4
Abnormal flexion in response to pain (decorticate rigidity)    3
Extension in response to pain (decerebrate rigidity)             2
No response                                                                     1

Quetiapine
What is quetiapine (Seroquel®)?
Seroquel® is an antipsychotic drug commonly used to treat bipolar
disorder, depression, and schizophrenia. Seroquel® is in a class of drugs called
antipsychotics.  The drug is believed to act by blocking dopamine,serotonin, histamine-
1, and alpha-1 adrenergic receptors, thus reducing psychomotor agitation or mania.
Quetiapine (Seroquel®) should decrease:

 Excited or manic behavior

 Depression

 Delusions

 Delusions and hallucinations

Side effects  that may occur with quetiapine (Seroquel®) include:

 Suicidal ideations or tendencies

 Hypotension

 Extrapyramidal symptoms (i.e. akathisia, dystonia, dyskinesia).

 Respiratory distress

 Tachycardia

Documentation
Documenting your patient's mental status as specifically as possible is extremely
important. If you respond to this type of scenario in someone's home, document all
scene survey clues (i.e. prescribed and over-the-counter medicines). Check the dates
that medication bottles were filled and see if there are too many pills or not enough
pills missing. 

Also, it is not uncommon for patients taking psychiatric medications to ingest other
substances (i.e. alcohol, over-the-counter medications). Document any significant
findings from the scene survey that could have relevance to the patient's condition.
Document if there are alcohol bottles that appear to be recently emptied. Be thorough
and be factual without making assumptions.
What Happened To Our Patient?
At the Emergency Department, our patient underwent a lumbar puncture and an MRI of
the brain, revealing viral encephalitis. Our patient slowly improved over the next 2-3
weeks. 
This is a classic scenario of being presented with a number of possibilities to explain a
patient's signs and symptoms. You must be the detective and sift through possibilities. 
On this occasion, you have a patient with a history of schizophrenia and anxiety, recent
head trauma, is an unreliable historian, and isn't capable of determining if
his medication has been taken properly. 
Being familiar with the many causes of acute psychosis and conducting an extremely
thorough assessment and history will help ensure your patient receives timely and
appropriate care.

Glossary
Abuse  : Any form of maltreatment that results in harm or loss. Maltreatment may be
physical, sexual, psychological, or financial/material.
Adrenergic  : Pertaining to nerves that release the neurotransmitter norepinephrine or
noradrenaline (such as adrenergic nerves, adrenergic response). The term also pertains
to the receptors acted on by norepinephrine, that is, the adrenergic receptors.
Agitation  : Extreme restlessness and anxiety.
Behavior  : The way people act or perform, for example how they react/respond to a
situation.
Coma  : A state in which one does not respond to verbal or painful stimuli.
Delirium  : Change in mental status that is marked by the inability to focus, think
logically, and maintain attention.
Dementia  : The slow onset of progressive disorientation, shortened attention span, and
loss of cognitive function.
Depression  : A persistent mood of sadness, despair, and discouragement; may be a
symptom of many different mental and physical disorders, or it may be a disorder on its
own.
Drug  : Substance that has some therapeutic effect (such as reducing inflammation,
fighting bacteria, or producing euphoria) when given in the appropriate circumstances
and in the appropriate dose.
Drug Abuse  : Any use of drugs that causes physical, psychological, economic, legal, or
social harm to the user or others affected by the user's behavior.
Drugs  : Any chemical compounds that may be used on humans to help in diagnosis,
treatment, cure, mitigation, or prevention of disease or other abnormal conditions.
Etiology  : The cause of a disease process.
Flat  : Used to describe behavior in which the patient doesn't seem to feel much of
anything at all.
Hyperglycemia  : Abnormally high blood glucose level.
Hypoglycemia  : Abnormally low blood glucose level.
Illicit  : In relation to drugs, illegal drugs such as marijuana, cocaine, and LSD.
Infection  : The abnormal invasion of a host or host tissue by organisms such as
bacteria, viruses, or parasites, with or without signs or symptoms of disease.
Lead  : Any one of the conductors, composed of two or more electrodes, in the ECG that
shows the electrical conduction in the heart.
Medication  : A licensed drug taken to cure or reduce symptoms of an illness or medical
condition or as an aid in the diagnosis, treatment, or prevention of a disease or other
abnormal condition.
Meningitis  : An inflammation of the meningeal coverings of the brain and spinal cord; it
is usually caused by a virus or bacterium.
Metabolic  : Pertaining to the breakdown of ingested foodstuffs into smaller and smaller
molecules and atoms that are used as energy sources for cellular function.
Mortality  : Deaths caused by injury and disease. Usually expressed as a rate, meaning
the number of deaths in a certain population in a given time period divided by the size
of the population.
Perception  : The way a person processes the data supplied by the five senses.
Postictal  : The period of time after a seizure during which the brain is reorganizing
activity.
Psychiatric Emergency  : An emergency in which abnormal behavior threatens an
individual's health and safety or the health and safety of another person, for example
when a person becomes suicidal, homicidal, or has a psychotic episode.
Psychosis  : Breaking with common reality and existing mainly within an internal world.
Recognition  : The ability to identify information that one has encountered before.
Restlessness  : A situation in which the patient can't sit still.
Seizure  : A paroxysmal alteration in neurologic function, ie, behavioral and/or
autonomic function.
Sepsis  : A pathologic state, usually in a febrile patient, resulting from the presence of
invading microorganisms or their poisonous products in the bloodstream.
Signs  : Indications of illness or injury that the examiner can see, hear, feel, smell, and
so on.
Skull  : The structure at the top of the axial skeleton that houses the brain and consists
of 28 bones that comprise the auditory ossicles, the cranium, and the face.
Substance Abuse  : Use of a substance that disrupts activities of daily living.
Symptoms  : The pain, discomfort, or other abnormality that the patient feels.
Track Marks  : The visible scars from repeated cannulation of a vein; commonly
associated with illicit drug use.

References
1. Pollak AN (Ed.): Nancy Caroline's Emergency Care in the Streets. 6th edition.
Jones and Bartlett Publishers, Boston, 2008.

2. Pollak AN (Ed.): Emergency Care and Transportation of the Sick and Injured. 9th
edition. Jones and Bartlett Publishers, Boston, 2005.

3. Tintinalli JE: Emergency Medicine. 7th edition. McGraw-Hill, New York, 2011.

4. Jibson MD: Overview of Psychosis, www.UpToDate.com, February 25, 2010. 

5. Jibson MD: Schizophrenia: Epidemiology and pathogenesis, www.UpToDate.com,

May 27, 2011. 
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