Acute Psychosis / Agitation

Related Subjects: |Depression |Mania |Schizophrenia |Suicide |Acute Psychosis |General Anxiety Disorder |Obsessive-Compulsive disorder |Wernicke Korsakoff Syndrome |Medically Unexplained symptoms

🧠 Psychosis describes a state in which a person loses some contact with reality. It commonly presents with hallucinations, delusions, and disturbed thinking or behaviour. Always remember: an acute psychotic presentation may be primary psychiatric illness, but it may also reflect delirium, intoxication, withdrawal, neurological disease, or other medical pathology.

ℹ️ About

• Psychosis is a syndrome in which thoughts, perceptions, and interpretation of reality become significantly distorted.
• Patients may experience hallucinations (perceptions without an external stimulus), most commonly auditory.
• They may also develop delusions — fixed false beliefs that are not explained by cultural or religious background.
• An episode of hallucinations, delusions, and behavioural disturbance is often referred to as a psychotic episode.
• Psychosis is a clinical presentation, not a diagnosis in itself: causes include schizophrenia, bipolar disorder, severe depression, substance misuse, and organic brain disease.

🧠 Core Symptoms of Psychosis

• Hallucinations: hearing, seeing, or sensing things that are not externally present; auditory hallucinations are most typical.
• Delusions: fixed false beliefs, often persecutory, grandiose, somatic, or referential.
• Thought disorder: disorganised, tangential, or incoherent speech reflecting disturbed thinking.
• Passivity phenomena: beliefs that thoughts, actions, or feelings are being controlled by an outside force.
• Behavioural change: agitation, withdrawal, suspiciousness, disinhibition, or bizarre behaviour.
• Lack of insight: the patient may not recognise that their experiences are abnormal.

📊 Epidemiology / Risk Factors

• Psychotic disorders most often begin in late adolescence or early adulthood.
• First-episode psychosis commonly presents in men under 30 and women under 35, though it can occur at any age.
• Substance misuse is an important risk factor, especially cannabis, amphetamine, cocaine, and synthetic drugs.
• Other risks include family history, psychosocial stress, sleep deprivation, trauma, and neurodevelopmental vulnerability.
• In older adults, always think carefully about delirium, dementia-related illness, medication effects, or neurological disease before assuming a primary psychotic disorder.

🩺 Clinical Features

• Persecutory / paranoid delusions: beliefs that others intend harm, are spying, or are plotting against the patient.
• Grandiose delusions: beliefs of special identity, exceptional powers, or important missions.
• Delusions of reference: ordinary events, media, or conversations are believed to have special personal meaning.
• Thought interference: thought insertion, withdrawal, or broadcasting.
• Passivity phenomena: experiences of being controlled in thought, action, or bodily sensation.
• Third-person auditory hallucinations: voices commenting on or discussing the patient.
• Negative symptoms: reduced motivation, emotional flattening, poverty of speech, and social withdrawal.

🚨 Red Flags for Organic / Medical Causes

• Fluctuating consciousness or inattention → think delirium.
• New focal neurology, headache, seizures, or cognitive decline → think neurological disease.
• Fever, autonomic instability, meningism, or severe confusion → consider infection / encephalitis.
• Recent substance use, intoxication, or withdrawal.
• Older age at first presentation without prior psychiatric history.
• Acute visual hallucinations may point more strongly toward delirium, Lewy body disease, or intoxication than primary schizophrenia.

🧍 Examination

• Mental state examination: appearance, behaviour, speech, mood, thought form, thought content, perception, cognition, insight, and risk.
• Cardiovascular: pulse, blood pressure, arrhythmia risk, signs of stimulant use or heart failure.
• Respiratory: hypoxia, chest infection, smoking-related disease, aspiration risk.
• Abdominal / gastrointestinal: hepatic disease, alcohol-related illness, constipation, urinary retention, or other contributors to delirium.
• Neurological: focal deficits, meningism, movement disorder, seizures, encephalopathy, or head injury.
• Endocrine / general: thyroid disease, steroid effects, Cushingoid features, dehydration, malnutrition.

🧠 Differential Diagnoses

• First-episode psychosis / schizophrenia spectrum disorder.
• Bipolar affective disorder with manic psychosis.
• Severe depressive episode with psychotic features.
• Schizoaffective disorder.
• Substance-induced psychosis or intoxication / withdrawal state.
• Delirium due to infection, metabolic disturbance, organ failure, or medication.
• Neurological disease such as temporal lobe epilepsy, encephalitis, tumour, autoimmune encephalitis, or dementia.
• Obsessive-compulsive disorder, PTSD, personality disorder, or dissociative disorder where reality testing may appear disturbed but the syndrome is different.

🔎 Investigations

• Bedside tests: observations, capillary glucose, ECG, and where relevant a pregnancy test.
• Urine drug screen: consider cannabis, cocaine, amphetamines, opioids, benzodiazepines, and other substances depending on context.
• Blood tests:
  • FBC – anaemia, infection, inflammatory clues.
  • U&Es / creatinine – dehydration, renal failure, electrolyte disturbance.
  • LFTs – hepatic encephalopathy, alcohol-related disease, drug effects.
  • CRP – inflammatory / infective process.
  • Glucose / HbA1c – hypoglycaemia, diabetes, baseline metabolic risk.
  • TFTs – hyperthyroidism or hypothyroidism.
  • Calcium – hypercalcaemia can cause confusion / psychosis.
  • B12 / folate – if deficiency is plausible.
  • Cortisol or other endocrine tests if clinically indicated.
  • HIV / syphilis serology when relevant.
• LP if meningitis, encephalitis, or inflammatory CNS disease is suspected.
• EEG if temporal lobe epilepsy, non-convulsive seizure activity, or encephalopathy is suspected.
• CT or MRI brain if there are focal signs, head injury, seizures, atypical presentation, or concern about structural pathology.

💊 Management

• Make the environment safe: calm setting, low stimulation, clear communication, reduce confrontation.
• Assess risk urgently: risk to self, risk to others, vulnerability, self-neglect, suicidality, and safeguarding concerns.
• Exclude medical causes first, especially delirium, intoxication, hypoglycaemia, infection, and neurological illness.
• Early psychiatric input is essential, especially for first-episode psychosis or severe behavioural disturbance.
• Oral medication is preferred if the patient is willing and able to take it.
• Rapid tranquillisation is only for situations where the patient poses immediate risk and de-escalation has failed.
• Monitor physical health: observations, hydration, nutrition, ECG where indicated, and metabolic baseline if starting antipsychotics.
• Address substance misuse early, as this may be causal, exacerbating, or a barrier to recovery.
• Psychosocial support is important from the outset: family engagement, community mental health support, and early intervention services where appropriate.

🚨 Acute Agitation / Behavioural Disturbance

• Start with verbal de-escalation, one lead communicator, and a low-stimulation environment.
• Check for delirium, intoxication, withdrawal, hypoxia, hypoglycaemia, and head injury.
• If medication is required urgently for safety, follow local rapid-tranquillisation guidance and monitor closely afterwards.
• Always document capacity, risk, rationale, observations, and response to treatment.

🧠 Oral Antipsychotics (First-line for psychosis if cooperative)

• Olanzapine: 5–10 mg once daily → titrate to 5–20 mg/day ⚠️ High metabolic risk (weight gain, diabetes)
• Risperidone: 1 mg daily → increase to 2–6 mg/day (usually BD dosing) ⚠️ Prolactin ↑, EPS at higher doses
• Aripiprazole: 10–15 mg once daily → usual range 10–30 mg/day ⚠️ Akathisia, less sedating
• Quetiapine: 25–50 mg BD → titrate up (usual 300–600 mg/day) ⚠️ Sedation, hypotension, metabolic effects
• Haloperidol (oral): 0.5–1 mg BD/TDS → titrate (usual 2–10 mg/day) ⚠️ EPS, QT prolongation

💡 Start low, go slow — especially in elderly/frail patients.

🚨 Rapid Tranquillisation (NICE NG10 – Adults)

• IM Lorazepam: 1–2 mg ➡️ Repeat after 30–60 min if required (max usually 4 mg in 24h, use caution in frail)
• IM Haloperidol + IM Promethazine: Haloperidol 2.5–5 mg IM and Promethazine 25–50 mg IM ➡️ Can repeat after ~1 hour if needed (max haloperidol usually ≤20 mg/day)

⚠️ Use IM lorazepam alone if: antipsychotic-naive, unknown history, prolonged QT risk, or no ECG available.

🧓 Elderly / Frail Patients

• Haloperidol: 0.25–0.5 mg PO/IM → very cautious titration
• Lorazepam: 0.5–1 mg (avoid oversedation)
• ⚠️ High risk of falls, oversedation, aspiration, and delirium worsening

🤰 Special Situations

• Parkinson’s disease / Lewy body dementia: 🚫 Avoid haloperidol → consider specialist advice (e.g., quetiapine)
• Alcohol withdrawal: ➡️ Benzodiazepines (e.g., diazepam) are first-line, not antipsychotics
• Severe agitation with intoxication: ➡️ Prefer lorazepam, avoid excessive sedation

📊 Monitoring After Starting Treatment

• Observations: pulse, BP, respiratory rate, temperature
• ECG: especially if using haloperidol or QT risk
• Bloods: glucose, lipids, U&Es
• Weight / BMI regularly
• EPS monitoring: rigidity, tremor, akathisia

⚠️ Maximum Dose Principles

• Always check BNF maximum doses before prescribing
• Avoid exceeding recommended limits without specialist input
• Use single antipsychotic where possible

🎓 Exam Pearls

• First-line = oral antipsychotic (if safe)
• Rapid tranquillisation = lorazepam OR haloperidol + promethazine
• Delirium ≠ psychosis → treat cause first
• Low dose in elderly — high complication risk
• QT prolongation → avoid haloperidol

🩺 Ongoing Monitoring

• Observations: pulse, blood pressure, temperature, respiratory rate, oxygen saturation if unwell or sedated.
• Fluid balance and nutrition: especially in acutely disturbed or neglected patients.
• Weight / BMI / waist circumference if commencing ongoing antipsychotic treatment.
• Metabolic monitoring: glucose, lipids, and cardiovascular risk over time.
• Smoking status: important because smoking affects both physical risk and metabolism of some psychotropic drugs.

🎓 Teaching Pearls

• Psychosis is a syndrome, not a diagnosis.
• First-episode psychosis always deserves a careful physical and neurological screen.
• Agitation in an older confused patient is delirium until proved otherwise.
• Auditory hallucinations are more typical of primary psychosis; visual hallucinations make organic causes more likely.
• Thought interference and third-person voices are classic high-yield psychotic symptoms in exams.

📖 References

• Managing the acute psychotic episode
• NICE CG178 – Psychosis and schizophrenia in adults