What is the appropriate management for a patient presenting with psychotic features?

Management of Psychotic Features

The first priority is to distinguish delirium from primary psychosis, as missing delirium doubles mortality—evaluate for fluctuating consciousness, disorientation, and inattention (delirium) versus intact awareness (psychosis), then systematically exclude secondary medical causes before initiating antipsychotic treatment. 1, 2

Initial Assessment and Critical Distinction

Delirium vs. Psychosis

• Delirium is the most common cause of psychotic symptoms in elderly patients presenting to emergency departments, characterized by inattention, fluctuating consciousness, and acute onset over hours to days. 2
• Unlike primary psychosis, delirium involves altered consciousness and disorientation, whereas psychosis typically maintains intact awareness and level of consciousness. 1, 3
• Missing this distinction is a critical pitfall that doubles mortality. 2

Key Clinical Features to Assess

• Consciousness level: Fluctuating or altered consciousness suggests delirium rather than primary psychosis. 1, 2
• Vital signs: Tachycardia or severe hypertension may indicate drug toxicity or thyrotoxicosis; fever may suggest encephalitis or porphyria. 4
• Onset pattern: Acute onset over hours to days suggests delirium or secondary causes; subacute onset should raise suspicion for oncologic causes. 4
• Hallucination type: Visual hallucinations are more common with medical causes; auditory hallucinations suggest primary psychiatric disorders. 4

Systematic Exclusion of Secondary Causes

Substance-Related Causes (Most Common)

• Illicit drug use is the most common medical cause of acute psychosis. 4
• Substance-related psychosis includes intoxication, withdrawal states, and medication side effects or toxicity. 1, 5
• Withdrawal states require immediate benzodiazepine treatment to prevent seizures—don't overlook this critical intervention. 2
• Substance-induced psychosis typically resolves within 30 days of abstinence from the substance. 6
• If psychotic symptoms persist for longer than one week despite documented detoxification, only then consider a primary psychotic disorder rather than substance-induced psychosis. 5

Medical Conditions to Evaluate

Secondary medical causes that directly produce psychotic symptoms include: 1, 2

• Endocrine disorders (thyrotoxicosis, parathyroid disorders)
• Autoimmune diseases (systemic lupus erythematosus, autoimmune encephalitis)
• Neoplasms and paraneoplastic processes
• Neurologic disorders (stroke, seizures, dementia, traumatic brain injury)
• Infections (encephalitis, meningitis, systemic infections with sepsis)
• Metabolic disorders
• Nutritional deficiencies (vitamin B12, folate, niacin)

Essential History Elements

• Recent head injury or trauma, seizures, cerebrovascular disease, or new or worsening headaches. 4
• Medication review for drug-related causes. 1, 2
• Collateral history from family members to establish presentation and course of illness. 4, 7

Diagnostic Workup

Laboratory Testing

Suggested initial laboratory tests include: 4

• Complete blood count
• Metabolic profile
• Thyroid function tests
• Urine toxicology
• Parathyroid hormone and calcium levels
• Vitamin B12, folate, and niacin levels
• HIV and syphilis testing (should be considered)

Neuroimaging Indications

Neuroimaging is not always required for new onset psychosis without neurologic deficits, but specific indications include: 1

• Focal neurologic deficits: Noncontrast head CT is usually appropriate as first-line test. 1
• Head trauma history: CT head without contrast indicated. 2
• Atypical presentation or unclear clinical picture: Either MRI or CT may provide helpful information. 1
• Abnormal findings on examination: Neuroimaging appropriate. 1
• New-onset psychosis in elderly patients: Higher suspicion for secondary causes. 2

The yield of CT in detecting pathology responsible for psychotic symptoms is very low (0% to 1.5%) in patients with new onset psychosis and no neurologic deficit. 1

The American College of Emergency Physicians recommends individual assessment of risk factors to guide the decision for neuroimaging in patients without neurologic deficits. 1

Treatment Approach

For Secondary Psychosis

• Treatment is aimed at the underlying medical cause and control of psychotic symptoms. 1, 3
• Management of delirium is based on treatment of the underlying cause, control of symptoms with nonpharmacological approaches, medication when deemed appropriate, and effective aftercare planning. 1

For Primary Psychosis

Treatment involves pharmacologic management with antipsychotic medications, psychological therapy, and psychosocial interventions. 1, 3

Antipsychotic Medication Selection

• Second-generation antipsychotics are typically first-line for primary psychosis, with specific choice depending on the patient's symptoms, desired outcomes, and adverse effect profile. 6
• For acute agitation in schizophrenia or bipolar mania, intramuscular olanzapine 5-10 mg has demonstrated efficacy, with doses of 7.5 mg and 10 mg showing larger and more consistent effects. 8
• Risperidone has established efficacy in schizophrenia (1-6 mg/day), bipolar mania (1-6 mg/day), and as adjunctive therapy with lithium or valproate. 9

Special Populations

• Antipsychotic medications should be used with caution in older adults and patients with dementia-related psychosis due to the associated risk of mortality. 6
• In pediatric bipolar mania (ages 10-17), risperidone 0.5-2.5 mg/day demonstrated comparable efficacy to higher doses (3-6 mg/day), with no trend toward greater efficacy at doses higher than 2.5 mg/day. 9

Disposition and Referral

• All patients presenting with first episode psychosis for which no organic cause can be found should be referred to the local early intervention service. 7
• Consider referral for patients with known diagnosis if there is poor response or nonadherence to treatment, intolerable side effects, comorbid substance misuse, or risk to self or others. 7

Common Pitfalls to Avoid

• Don't assume primary psychiatric disorder without systematic exclusion of secondary causes—approximately 20% of acute psychosis cases have a medical cause. 10
• Don't delay neuroimaging when focal neurological signs, head trauma history, or atypical features are present. 2
• Don't overlook trauma history and dissociative phenomena—maltreated children with PTSD report significantly higher rates of psychotic symptoms that may actually represent dissociative phenomena rather than true psychosis. 5
• Don't diagnose MDD with psychotic features after only 3 days of symptoms—substance-induced psychosis, delirium, and other secondary causes must be systematically excluded first. 5