What is the approach and management for a patient presenting with acute psychosis?

Approach and Management of Acute Psychosis

Initial Assessment and Stabilization

The first priority is to distinguish primary psychiatric psychosis from secondary medical causes through focused history, physical examination with attention to vital signs and neurologic findings, and targeted laboratory testing—routine screening is not indicated in stable patients. 1

Key Clinical Features to Identify

• Assess level of consciousness first: Intact awareness distinguishes psychosis from delirium, which requires different urgent management. Fluctuating consciousness, disorientation, and inattention indicate delirium, not primary psychosis. 1, 2

• Evaluate cardinal psychotic symptoms: Delusions, hallucinations, disorganized speech/thought, abnormal motor behavior (including catatonia or agitation), and negative symptoms (diminished emotional expression). 1

• Check vital signs carefully: Tachycardia or severe hypertension suggests drug toxicity or thyrotoxicosis; fever may indicate encephalitis, porphyria, or CNS infection. 1, 3

• Perform focused neurologic examination: Look for focal deficits suggesting structural brain lesions requiring urgent imaging. Test for asterixis and myoclonus which indicate metabolic encephalopathy rather than primary psychosis. 2, 4

Distinguishing Primary vs Secondary Psychosis

Primary psychosis typically presents with auditory hallucinations, prominent cognitive disorders, and complicated delusions, while secondary causes more often show visual hallucinations, abnormal vital signs, and cognitive changes. 3

Secondary causes to actively exclude: 1

• Drug-related: Illicit substances (most common medical cause), alcohol withdrawal, medication toxicity, anticholinergics
• CNS pathology: Stroke, hemorrhage, tumor, infection (meningitis, encephalitis), traumatic brain injury, seizures
• Metabolic/Endocrine: Hypoglycemia, hyperglycemia, hyponatremia, hypocalcemia, thyroid disease, Cushing disease
• Other: Hypoxia, carbon monoxide poisoning, autoimmune encephalitis, paraneoplastic syndromes

Diagnostic Testing Strategy

Order laboratory tests and imaging based on history and physical examination findings—not as routine screening. 1

When patients are clinically stable (alert, cooperative, normal vital signs, noncontributory history/physical), routine laboratory testing is not indicated. 1

For patients with concerning findings (altered mental status, abnormal vital signs, new-onset psychosis, atypical presentation), consider: 1, 4

• Complete blood count, metabolic panel, calcium, thyroid function
• Vitamin B12, folate, niacin levels
• Toxicology screen (only when indicated by history—routine screening has minimal utility and rarely changes management) 1
• HIV and syphilis testing when appropriate
• Renal and hepatic function for medication monitoring

Neuroimaging indications: 1, 4

• New-onset psychosis with focal neurologic deficits (CT head without contrast is usually appropriate first-line)
• Atypical presentation or abnormal neurologic examination
• History of head trauma, new/worsening headaches, or subacute onset suggesting oncologic cause
• Brain MRI is preferred over CT when neuroimaging is indicated 4
• Routine brain imaging in stable psychiatric patients has extremely low yield (1.2-5% abnormalities, none clinically relevant) 1

Pharmacological Management

Begin antipsychotic treatment for patients with psychotic symptoms lasting one week or more with associated distress or functional impairment, using atypical antipsychotics as first-line due to better tolerability. 5

Initial Antipsychotic Dosing

Avoid large initial doses—they increase side effects without hastening recovery. 2, 5

Recommended initial target doses: 5

• Risperidone: 2 mg/day
• Olanzapine: 7.5-10 mg/day

Any immediate calming effects are due to sedation; true antipsychotic effects become apparent after 1-2 weeks. 5

Treatment Timeline and Response Assessment

Implement treatment for 4-6 weeks using adequate dosages before determining efficacy. 2, 5

Short-term benzodiazepines as adjuncts to antipsychotics may help stabilize the acute situation. 5

Monitor closely for extrapyramidal side effects, which must be avoided to encourage future medication adherence. 5

If First Treatment Fails

If no response after 4-6 weeks or intolerable side effects develop, switch to a different antipsychotic with a different pharmacodynamic profile. 2, 5

For patients whose first-line treatment was a D2 partial agonist, consider amisulpride, risperidone, paliperidone, or olanzapine as second-line treatment. 5

Treatment-Resistant Psychosis

If positive symptoms remain significant after two adequate treatment trials (at least 4 weeks each), reassess diagnosis and contributing factors. 5

Consider clozapine for treatment-resistant cases—it is the only antipsychotic with documented superiority for treatment-refractory schizophrenia, but should only be used after failure of at least two therapeutic trials of other antipsychotics (at least one atypical). 1, 5

Safety and Risk Assessment

Evaluate for suicide risk in all patients—psychosis carries a 10% lifetime suicide risk. 6, 7

Patients at high risk (continued desire to die, severe hopelessness, inability to engage in safety planning, inadequate support system, high-lethality attempt) require consideration for inpatient psychiatric admission once medically cleared. 1

For patients with suicidal ideation, implement personal and belongings search, hospital attire, safe environment without access to medical equipment, and close staff supervision. 1

Psychosocial Interventions and Continuity

Include families in assessment and treatment planning from the outset, providing emotional support and practical advice. 2, 5

Progressively educate families and social network about the nature of the problem, treatments, and expected outcomes. 5

Ensure continuity of care with the same treating clinicians for at least the first 18 months of treatment. 2, 5

Provide treatment in outpatient or home settings when possible and safe; reserve inpatient care for severe crises or safety concerns. 5

Critical Pitfalls to Avoid

• Don't miss delirium: Fluctuating consciousness distinguishes it from psychosis and requires different urgent evaluation 2, 4
• Don't overlook withdrawal states: Alcohol or benzodiazepine withdrawal causes both psychosis and life-threatening seizures requiring immediate benzodiazepine treatment 2
• Don't delay neuroimaging when focal signs, head trauma, or atypical features are present 2
• Don't switch medications too early (before 4-6 weeks) or continue ineffective treatment too long 5
• Don't use excessive initial dosing—it causes unnecessary side effects without faster recovery 2, 5
• Don't perform routine toxicology screening in stable patients—it rarely changes management 1

Special Populations

Elderly patients with dementia-related psychosis have increased mortality risk with antipsychotic treatment (1.6-1.7 times placebo); antipsychotics are not approved for this indication. 8, 6

For adolescents with schizophrenia, risperidone 1-6 mg/day has demonstrated efficacy, with doses above 3 mg/day showing no additional benefit. 8