What is the diagnosis and treatment for a 48-year-old male with a history of traumatic emotional experience, presenting with delusions, agitation, sleep disturbance, and rigid joints, and is it bipolar disorder, schizophrenia, or a medical condition?

Diagnosis and Management of Acute Psychosis with Catatonic Features

Most Likely Diagnosis

This presentation most strongly suggests a medical or substance-induced psychosis with catatonic features, rather than primary bipolar disorder or schizophrenia, given the acute onset over 3 days, prominent visual hallucinations, rigid joints with spinal hyperextension (catatonic features), and temporal relationship to a traumatic stressor. 1, 2, 3

Diagnostic Approach

Immediate Priority: Rule Out Medical Emergencies

The acute 3-day timeline with rigid joints and hyperextension demands urgent evaluation for:

• Neuroleptic malignant syndrome (if any prior antipsychotic exposure) - characterized by rigidity, altered mental status, and autonomic instability 1
• Catatonia - the rigid joints with spinal hyperextension are classic catatonic features requiring immediate benzodiazepine trial 1, 2
• Central nervous system infections (meningitis, encephalitis) - acute psychosis with motor abnormalities 1, 2
• Metabolic encephalopathy - check for asterixis, myoclonus suggesting metabolic derangement 1
• Substance intoxication or withdrawal - particularly alcohol or benzodiazepine withdrawal which can cause psychosis and life-threatening seizures 1

Key Diagnostic Distinctions

Visual hallucinations are the strongest indicator of a medical rather than primary psychiatric cause - this patient "talks to air" and has delusions about animals killing him, suggesting possible visual hallucinations. 3

The acute 3-day onset argues strongly against schizophrenia or bipolar disorder:

• Schizophrenia requires at least 6 months of symptoms including prodromal phases 2
• First-episode psychosis typically develops over weeks to months, not 3 days 3
• Delirium develops acutely over hours to days, making this timeline more consistent with medical causes 3

Catatonic features (rigid joints, spinal hyperextension) can occur in:

• Medical conditions (encephalitis, metabolic disorders) 1, 2
• Substance-induced states 1
• Severe mood disorders with psychotic features 2
• Schizophrenia (but timeline doesn't fit) 2

Essential Workup

Neuroimaging is indicated - new-onset psychosis with catatonic motor features requires brain imaging to exclude structural lesions, particularly given the atypical presentation. 1, 2

Laboratory evaluation must include:

• Complete metabolic panel, electrolytes (metabolic encephalopathy) 3
• Toxicology screen (substance-induced psychosis) 1
• Complete blood count (infection, systemic illness) 3
• Thyroid function, B12, RPR (reversible causes) 3
• Lumbar puncture if any concern for CNS infection 1, 2

Assess level of consciousness carefully - intact awareness and orientation argue against delirium, though delirium can fluctuate. 2, 3

Treatment Algorithm

Immediate Management (First 24-48 Hours)

For catatonic features (rigid joints, spinal hyperextension):

• Benzodiazepines are first-line - lorazepam 1-2 mg IM/IV as diagnostic and therapeutic trial 4
• Response to benzodiazepines within 30-60 minutes supports catatonia diagnosis 1

For acute agitation and psychotic symptoms causing distress:

• Short-term antipsychotic use is warranted despite lack of evidence for routine use, when patient experiences significant distress from hallucinations/delusions or poses safety risk to self/others 4
• Haloperidol or atypical antipsychotics (risperidone, olanzapine, quetiapine) can be used for acute symptom control 4
• Avoid large initial doses - they increase side effects without hastening recovery 1

Specific dosing for acute psychosis with agitation:

• Risperidone: Start 0.25-0.5 mg, maximum 2-3 mg/day (lower doses reduce extrapyramidal symptoms) 4
• Olanzapine: Start 2.5-5 mg, maximum 10 mg/day (generally well tolerated) 4, 5
• Quetiapine: Start 12.5-25 mg twice daily, maximum 200 mg twice daily (more sedating, useful for insomnia) 4
• Haloperidol: Use lowest effective dose due to extrapyramidal symptom risk 4

For insomnia (unable to sleep for 3 days):

• Benzodiazepines (lorazepam, temazepam) for short-term use to stabilize sleep disturbance 4
• Quetiapine offers dual benefit of antipsychotic effect plus sedation 4
• Avoid prolonged benzodiazepine use (tolerance, addiction risk) 4

Ongoing Management (Days 3-7)

Continue antipsychotic treatment for 4-6 weeks before determining efficacy - therapeutic effects typically become apparent after 1-2 weeks. 1

If symptoms persist after adequate trial:

• Switch to another antipsychotic with different pharmacodynamic profile 1
• Reassess for underlying medical causes if no improvement 1, 3

Monitor for:

• Metabolic changes (weight gain, glucose, lipids) 5
• Extrapyramidal symptoms and tardive dyskinesia 4, 5
• Orthostatic hypotension 5
• Neuroleptic malignant syndrome (fever, rigidity, altered mental status) 5

Disposition and Follow-up

Discontinue antipsychotics immediately once distressing symptoms resolve - patients started on antipsychotics in acute settings often remain on them unnecessarily, causing significant morbidity and cost. 4

If substance-induced psychosis is confirmed:

• Symptoms typically resolve within days to weeks after substance discontinuation 2
• Treatment focuses on underlying cause and symptom control 2

If primary psychiatric disorder emerges:

• Maintain continuity of care with same clinicians for at least 18 months 1
• Include family in treatment planning and provide emotional support 1

Critical Pitfalls to Avoid

Missing delirium doubles mortality - fluctuating consciousness, disorientation, and inattention distinguish delirium from psychosis and require urgent medical evaluation. 3

Don't overlook withdrawal states - alcohol or benzodiazepine withdrawal can cause both psychosis and life-threatening seizures requiring immediate benzodiazepine treatment. 1

Don't delay neuroimaging when focal neurological signs, head trauma history, or atypical features (like acute catatonia) are present. 1, 2

Don't assume primary psychiatric disorder with acute 3-day onset - this timeline strongly suggests medical/substance etiology requiring different management. 1, 2, 3

Don't continue antipsychotics indefinitely if started for acute symptom control - reassess need regularly and discontinue when symptoms resolve. 4