Cant miss causes of Psychosis in Emergency Dept.

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13-23% of people experience psychotic symptoms at some point in their lifetime resulting from a number of organic causes (Perala, 2007; van Os, 2001).

“we cannot make the diagnosis if it’s not on our differential”



The presence of the following are more consistent with an organic cause of psychosis (Sheitman, 1997):

  • Acute onset
  • >40 yo w/o previous history of psychiatric diagnosis
  • Presents in general medical or intensive care settings
  • Non-auditory hallucinations (eg, visual, tactile, olfactory)
  • Abnormal vital signs
  • Lethargy
  • Clouded sensorium
  • Disorientation
  • Memory loss
  • Acute change from baseline function
  • Coexisting medical conditions
  • ***timing is sudden and reaches maximum severity acutely

Presence of any one of the following 4 factors that favor organic vs. functional psychosis can be used as triage method (Dubin, 1983):

  • Abnormal vital signs (T > 37.7, RR 25, HR 100, BP 160)
  • Clouded mental status (inability to follow train of thought)
  • >40 yo w/ no psych history
  • Disorientation (if miss at least two when asked: day, month, year, city, place)

Cant miss causes

[D] - Drugs / Toxins

  1. Polypharmacy
  2. Steroids
  3. Anticholinergics
  4. Levodopa / DA agonists
  5. Dextromethorphan
  6. Intoxications
    1. Cocaine
    2. MDMA (esctacy)
    3. PCP
    4. LSD
    5. Ketamine
    6. Cannabis
  7. Withdrawal
    1. Alcohol
    2. Sedative-Hypnotics
    3. Opioid

[I] - Infective

  1. Cystitis
  2. Meningitis or Encephalitis
  3. Septic shock

[V] - Vascular

  1. Stroke
  2. Cardiac / Respiratory [Hypoxia]
    1. MI
    2. CHF exacerbation
    3. Pneumonia
    4. Asthma attack
    5. COPD exacerbation

[I] - Inflammatory

  1. Lupus ceribritis

[N] - Nutritional

  1. Wernicke enceph / Korsakoff psychosis

[E] - Endocrine 

  1. Hypoglycemia
  2. Significant hyperglycemia [DKA, HONK]
  3. Myxedema madness - hypothyroid
  4. Thyroid storm - hyperthyroid
  5. Pheochromocytoma

[M] - Metabolic

  1. Uremic encephalopathy
  2. Hepatic encephalopathy
  3. Hypo / hypernatremia
  4. Hypo / Hypercalcemia
  5. Hypo / hyperkalemia

[D] - Degenrative

  1. Dementia

[T] - Trauma

  1. Head injury
  2. Hypovolemic shock

[T] - Tumor

  1. Brain
  2. Limbic encephalitis

[S] - Seizure

Following section is under construction

Geriatric population, multiple comorbidities, Anticholinergic cognitive burden scale, Another calculator.

  • H/o steroid treatment for varied conditions like Neurologic, rheumatologic, GI, respiratory, oncologic illnesses.
  • Weighted average incidence of steroid psychosis 27.6%.
  • Symptoms may vary from subtle anxiety/depression to full-blown affective and psychotic syndromes.
  • High steroid levels increase DA levels in a Dose-dependent manner.
  • Among patients taking prednisone, psychiatric disturbances are seen in 1.3% of patients taking less than 40 mg/day, 4.6% of patients taking 40-80 mg/day and 18.4% of patients taking more than 80 mg/day. Steroid equivalence dose calculator.
  • case report1, case report2

  • Psychiatric symptoms often develop after 4 days of corticosteroid therapy, although they can occur late in therapy or after treatment ends. Delirium often resolves within a few days, psychosis within 7 days, and mania within 2 to 3 weeks, whereas depression can last for more than 3 weeks. 

    Grade Symptoms
    1 Mild, nonpathologic, and subclinical euphoria
    2 Reversible acute or subacute mania and/or depression
    3 Bipolar disorder with relapses possible without steroids

    A 3-level grading system can gauge severity of corticosteroid-induced psychosis; grade 2 or 3 warrants treatment

  • Managment: A] taper steroid to lowest possible dose [less than 40mg/d dose equivalent of prednisolone] or gradually discontinuing therapy to prevent triggering adrenal insufficiency B] add adjunctive medication if clinically required - First line adjunct - low dose atypical like olanzapine, 2nd Line - Lithium [caution Li can worsen underlying conditions like renal dysfunction, SLE], third line - valproate and carbamazepine

  • Central Anticholinergic Effects

  • Peripheral Anticholinergic Effects

  • DA agonist like Levodopa, Cabergoline, Pramipexole, Ropinrole, Pergolide, Bromocriptine, Amantadine can theoritically cause psychosis by upregulating DA.
  • In PD patients, dementia and concomitant medication are associated with psychotic sx. Levodopa has lowest risk, whereas pergolide has highest risk. For all other dopaminergic drugs investigated, statistically reliable statements were not possible. link to study
  • Managment of drug induced psychosis in PD link to study
    • The first step of treatment is to eliminate triggering factors other than anti-PD drugs, such as infections, metabolic disorders, subdural hematoma, and hallucinogenic drugs.
    • The second step is to eliminate anti-PD drugs in the following order; first anticholinergics, amantadine and selegiline, second dopamine agonists, and finally levodopa/carbidopa.
    • Anti-PD medications should be reduced to the point of improving psychotic side effects without drastically worsening parkinsonian motor symptoms.
  • available in OTC cough and cold medications
  • also called the poor man's PCP
  • When consumed at inappropriately high doses (over 1500 mg/day), DXM can induce a state of psychosis characterized by Phencyclidine (PCP)-like psychological symptoms, including delusions, hallucinations, and paranoia.
  • case report1, case report2
  • higher risk in geriatrics, multiple medications

Check pockets for sharps and needles!

Acute: agitation, paranoia, hallucinations, hyperthermia. Chronic: cognitive impairment, suicidal ideation or attempt

Symptoms : AMS, seizures, restlessness, hyperthermia, ataxia, halos; palpitation, chest pain; GI complaints; Piloerection; Bruxism. May also present with serotonin syndrome. 

  • Developed as a dissociative general anaestehtic.
  • Presence of nystagmus in an awake and agiated patient is an important diagnostic clue. In other drugs causing nystagmus, pt is usually sedated.
  • Autonomic effects [at less than 5 mg dose] : HTN, Tachycardia, Tachypnea, Sweating
  • At higher doses, BP, HR and RR fall along with picture of obtundation
  • generalized numbness of extremities, loss of muscular coordination, dystonic reactions
  • Psychedelic
  • Sympathomimetic: sweating, flushing, piloerection, HTN, Tachycardia, mydriasis, tremors, hyperactive reflexes.
  • at higher doses: seizures, respiratory arrest, cardiac arrythmia.
  • h/o of persistent flashbacks
  • Psychosis with formication and agitation. Disorganized thniking is absent
  • sweating, flushing, HTN, Tachycardia, mydriasis, cardiac irregularities, eventually, confusion, seizures, coma, or death.
  • Hallucinations, Disorientation and general confusion due to the drug's anesthetic nature, Drowsiness. Increased heart rate, Elevated blood pressure.
  • impaired motor coordination, euphoria, anxiety, sensation of slowed time, impaired judgment, social withdrawal) that developed during, or shortly after, cannabis use.
  • Two (or more) of the following signs, developing within 2 hours of cannabis use: (1) conjunctival injection (2) increased appetite (3) dry mouth (4) tachycardia

Alcohol withdrawal symptoms appear within 6-24 hours after stopping alcohol, are most severe after 36 – 72 hours and last for 2 – 10 days.

Symptoms include: Anxiety, sweating, tremors, increase HR and BP, insomnia, nausea and vomiting, diarrhea

Severe withdrawal involve: Seizures, Hallucinations, Delirium tremens, Extreme fluctuations in body temperature and blood pressure, Extreme agitation

Alcohol withdrawal scale [CIWA-Ar]

CIWA-Ar score Interpretation (Withdrawal severity)
0 – 9 Absent or minimal
10 – 15 Mild
16 – 20 Moderate
21 – 67 Severe

Benzodiazepine equivalence table

  • Hydration 2-4L of water; if required IV fluids; if required postssium and magnesium supplementation
  • Thiamine and Multivitamins
  • Symptomatic Mx

Symptoms include: Anxiety, Insomnia, Restlessness, Agitation and irritability, Poor concentration and memory, Muscle tension and aches

Short-acting benzodiazepines include oxazepam, alprazolam and temazepam. Withdrawal typically begins 1-2 days after the last dose, and continues for 2-4 weeks or longer.

Long-acting benzodiazepines include diazepam and nitrazepam. Withdrawal typically begins 2-7 days after the last dose, and continues for 2-8 weeks or longer

No monitoring scale is recommended as symptoms can fluctuate markedly, rather reassess patient every 3-4 hrs. 

Calculating diazepam equivalent doses

Low-dose benzodiazepine reducing schedule

High-dose benzodiazepine reducing schedule

guidelines for withdrawal management

The Ashton Manual for Benzodiazepine Withdrawal Management

  • Opioids are drugs such as heroin, opium, morphine, codeine and methadone.
  • Withdrawal Sx

    • Short-acting opioids (e.g. heroin): Onset 8-24 hours after last use; duration 4-10 days.

    • Long-acting opioids (e.g. methadone): Onset 12-48 hours after last use; duration 10-20 days.

  • Sx include : Nausea and vomiting, Anxiety, Insomnia, Hot and cold flushes, Perspiration, Muscle cramps, Watery discharge from eyes and nose, Diarrhoea
  • guidelines for withdrawal management
  • SOWS - Short Opioid Withdrawal Scale
Symptom Not present Mild Moderate Severe
Feeling sick 0 1 2 3
Stomach cramps 0 1 2 3
Muscle spasms or twitching 0 1 2 3
Feeling cold 0 1 2 3
Heart pounding 0 1 2 3
Muscular tension 0 1 2 3
Aches and pains 0 1 2 3
Yawning 0 1 2 3
Runny/watery eyes 0 1 2 3
Difficulty sleeping 0 1 2 3

Score Suggested withdrawal management
0-10 Mild withdrawal; symptomatic medication only
10-20 Moderate withdrawal; symptomatic or opioid medication
20-30 Severe withdrawal; opioid medication

Dysuria, Urinary frequency, Hematuria. Other sx - Urinary urgency, Suprapubic Pain more

Headache, Nuchal rigitity, Fever, Nausea, Vomiting, Altered LOC, Focal deficits, Seizures. more

Temperature [Fever, Hypothermia(<36)]

Hypotension SBP <90, SBP drop >40, MAP <65

Cold clammy skin

Tachycardia

Low O2 level 

Additional = High WBC;  Incr ESR, CRP, PCT; 

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This page was last updated on 26/11/18.