Maryam Davari, MD

CMU Psychiatry Resident, PGY-3

Conflict of • I do not have any financial
interest/arrangement or affiliation with
Interest the organization offering financial

Disclosure support or an educational grant for this

continuing medical education activity.
 Learning
Objectives
• Understanding the characteristics of psychosis
• Identifying the possible causes of psychosis along
with the underlying pathophysiology.
• Recognizing recommended treatment approaches
and typical outcomes to management of psychosis
What Psychosis Means
to Most People…
 Where Did the Stigma Begin?
In the Medieval Era 
• People labeled to be “psychotic” were often placed in prisons
& dungeons along with criminals
• They received physical punishments & torture
• Religion was used to explain their symptoms & many of these
people were even accused of witchcraft
Transitions in Views on Mental Illness
• French psychiatrist, Philippe Pinel, took a different approach in
late 1700’s
• He began physically freeing people imprisoned for “psychosis”
• Also began searching for more scientific explanations for
symptoms
• He called this nonviolent management a “moral treatment”
 Where did • In 1841, Karl Friedrich
the actual Castatt was the first to coin
term “psychic neurosis” giving
“psychosis” more emphasis on how it
was result of brain disease
come from?
processes
• The exact meaning in
Greek
– Psyche=soul
– osis= Abnormality
 What Psychosis Really Means?
• “an abnormal condition of the mind that involves a blurring of or loss of
contact with reality”
• Can cause impaired thought process/content with problems in one’s
judgment
 Where is it most
commonly seen?

1. Emergency Department setting

2. Primary Care Provider’s office:
– this is usually the first point of contact for the majority of people
3. Hospital floors

*Psychiatry providers are usually NOT the first point of contact!

 Why it is • Studies have shown that 3.7% of primary
care patients have reported 1 or more
important psychotic symptoms
• 30% of patients with psychosis rely solely
to know the on a primary care provider for treatment

signs? • most mental health clinicians find that

individuals with 1st episode psychosis had
warning signs of illness during
adolescence & early adulthood.
• However, of the majority of persons
diagnosed with serious mental illness who
exhibit symptoms between the ages of
16-25, only about 50% of those
individuals obtain any type of diagnosis,
referral or treatment.
• The lack of early treatment interventions
available for persons that experience
psychosis often leads to individuals living
with a lifetime of disability.
Manifestations Usually present with 1 or
of Psychosis more of the following:
a. Delusions
b. Hallucinations
 Auditory, Visual,
Olfactory, and Tactile
c. Disorganization of
Thought
d. Disorganized Behaviors
 Delusions
• False beliefs a person holds that are not congruent with reality
• It is difficult to change the belief, even with evidence presented against it.
• Common delusions:

– Persecutory
– Grandiose
– Erotomanic
– Somatic
– Ideas of Reference
 Hallucinations
• sensory perceptions in the absence of external stimuli.
• Differ from illusions, or perceptual distortions, which are the
misinterpretation of external stimuli
• Auditory hallucinations are one of the most common features
of psychosis.
 Disorganized Thoughts/Behaviors
• decline in overall daily functioning
• Unpredictable or inappropriate
emotional responses
• Behaviors that appear bizarre and
have no purpose
• Lack of inhibition and impulse
control
• Speech Abnormalities: clanging,
loose associations, preservation,
neologisms, tangentiality, illogical
statements, derailment
Possible A. Medical
Causes
i. Intracranial
ii. Extracranial
• B. Psychiatric
Intracranial • Seizures
• Infections (HIV, syphilis, HSV, Lyme)
• Vascular- strokes, vasculitis
• Neoplasms
• Head Trauma
• Neurocognitive Impairments
(Dementias)
• Autoimmune (MS, SLE)
 Extracranial

• Drugs/ ETOH
• Medications
• Body Trauma
• Poisons/Toxins (Metals, Carbon Monoxide)
• Systemic Infections (UTI, URI, wounds)
• Endocrine (TSH, cortisol)
• Deficiencies (B12, folate, thiamine)
• Electrolyte Imbalance
Psychiatric
• Thought Disorders: Brief Psychotic Episode, Schizophreniform,
Schizophrenia, Schizoaffective Disorder, Delusional Disorder
• Mood Disorders: MDD or Bipolar Disorder w/ psychotic features
• Anxiety Disorders: PTSD, Panic Disorder
• Delusional Disorders
• Personality Disorders: Borderline Disorder
How to know • The problem you cannot immediately
know the cause of psychosis based upon
which is the the psychotic symptoms alone

cause? …..but there are clues!

• a new-onset episode of psychosis
cannot be considered a symptom of a
psychiatric disorder until other relevant
and known causes of psychosis are
properly excluded or ruled out

*Using the approach of the

biopsychosocial model can be helpful here
 Biopsychosocial Formulation=
Biology + Psychology + Social
Creating a hypothesis based off multi-factorial components
contributing to the presenting problem
Biology (Brain-Body) Psychology (Mind) Social (Environment)

Problem Sleep, appetite, Thought process, self- Isolation, avoidance

hallucinations, delusions image

Predisposing Factors Genes, family history Personality, cognitive Relationships, finances,

function, coping skills living environment

Precipitating factors Acute physical illness, Acute psychological trauma Divorce, unemployment,
medications, substances loss of loved one

Perpetuating Factors Chronic illness Poor adaptive responses Inability to establish social
network

Treatment Pharmacologic Psychotherapy Social Support

 HISTORY:

• Obtaining a history from a patient with psychotic symptoms may be

challenging. If possible, collateral information should be collected from family
members.
• History of Presenting Problem/Illness The temporal relationship and course of
psychotic symptoms can give clues on what is going on.
– For example, a 1st major break in schizophrenia usually occurs in late adolescence or
early adulthood.
– An onset of psychosis may occur acutely after recreational drug use or as a later
presentation in multiple sclerosis.
TYPES of • Patient's demographics
Age, sex, ethnicity, socioeconomic
HISTORIES class?
• Full medical history
Medical conditions, medications,
allergies, surgeries?
• Psychiatric history
Psychiatric conditions, psych
medications, hospitalizations,
outpatient care?
• Social history
Living environment, marital status, children,
education, occupation, supports, religion
• Family history
Both medical and psychiatric
• Substance use history
 MENTAL STATUS
– Appearance: grooming/hygiene, body habitus, clothing/style
– Behavior- cooperative, resistant, hyperactive, restless, withdrawn?
– Eye contact: avoidant, intense?
– Speech: clear, slurred, rapid, pressured, hyperverbal, slowed
– Activity Levels: agitated, slowed?
– Mood: euthymic, depressed, anxious, angry, euphoric
– Affect: constricted, labile, flat, full, reactive?
– Thought process: linear, logical, tangential, circumstantial
– Thought content: hallucinations, delusions, suicidal ideation, homicidal
ideation
– Insight/Judgment: intact or impaired
PHYSICAL EXAM
• Vitals-
– HR or BP: Tachycardia or HTN may indicate drug/substance toxicity, thyrotoxicosis
– Temperature: fever may suggest infectious component
• Appearance: may be suggestive of underlying disease
– Ex: cushingoid appearance may suggest endocrine cause, arthritic deformities in
autoimmune disorders, or movement and gait disturbances typical in multiple
sclerosis & Parkinson’s
– Signs of physical trauma to head or body
• Neurologic examination- focal signs, sensory deficits, myoclonus, tremors, Tendon
reflexes, cranial nerve testing, and ophthalmologic examination
• HEENT, DERM, CV, RESP, AB, Musculoskeletal
Labs/Imaging • Complete blood count- to assess for anemia,
elevated WBC
• Complete metabolic panel- renal/hepatic
function, electrolytes, and glucose
• Thyroid function tests
• Urinalysis and urine toxicology (substance use)
• Vitamins- B12, folate, D, and niacin
• If immunodeficiency suspected- HIV and
syphilis should also be considered.
• If there is concern for an autoimmune cause-
ANA and ESR may be useful
• Rare conditions, such as acute intermittent
porphyria disease, may be identified by urine
testing for porphyrins
• Emergency brain imaging is usually not
required unless the patient presents with new,
severe, unremitting headache; focal neurologic
deficits, or a history of recent significant head
trauma.
 Management
• Minimize sensory stimulation as you are formulating hypothesis about causes
• Assess patient safety need for 1:1 supervision?
– At times, chemical/physical restraints may be warranted if
patient a danger to self or others, but try to minimize use due
to possible worsening of psychosis
• Once cause is identified treatment can be tailored to address it
Pharmacologic Approaches
ANTIPSYCHOTICS:

Typical antipsychotic medications that are commonly used include:

• chlorpromazine, flupenthixol, fluphenazine, haloperidol, loxapine, perphenazine,
pimozide, thioridazine, trifluoperazine

Newer atypical antipsychotics include:

• Clozapine (Clozaril), olanzapine (Zyprexa), aripiprazole (Abilify), quetiapine
(Seroquel), risperidone (Risperdal), paliperidone (Invega)

• Current evidence suggests that all these medications are equally effective in
treating a first episode of psychosis. They will differ from one another in terms of
their side-effect profile., so some medications will be better tolerated by some
people
• Treatment begins with a low dose of medication that is monitored closely for any
side-effects.
 • BENZODIAZEPINES- can be helpful for
agitation at times, but you must keep in
mind they can have paradoxical effect
and worsen confusion

Pharmacologic – Also, goal is to use short term w/

Approaches
minimal amounts
• MOOD TREATMENTS
– adding antidepressant in conjunction
with antipsychotic for MDD w/ psychosis
– or mood stabilizer with antipsychotic in
mania w/ psychosis
(goal is also to use antipsychotic short-
term if possible)
 Psychologic • People recovering from a first episode
of psychosis often benefit from the
Interventions services of a case manager or therapist.
• A case manager/therapist provides
emotional support to the person and
family, education about the illness and
its management, and practical
assistance with day-to-day living.
• This assistance can help the person re-
establish a routine, return to work or
school, find suitable housing and obtain
financial assistance.
 In Summary
• Psychotic symptoms are debilitating & can be terrifying to patients & their families.
• Quick recognition of causes can improve treatment, consultation, & prognosis of the patient.
• Patients & family members should also be given therapeutic support with educational
literature/resources about their symptoms and outcomes.
• If psychosis is secondary to an organic cause, the physician has an opportunity to deliver a timely
intervention & management for acute causes or to ameliorate symptoms by providing long-term
patient and family-centered support for more chronic conditions.
• If there is a primary diagnosis of a psychiatric disorder, the patient will benefit from close
collaboration between mental health specialists and the primary care providers or specialists involved
in health treatment plans.
• Despite optimal treatment, patients psychotic disorders often have significant deficits in social
functioning.
• If the patient expresses suicidal ideation/intent or manifests symptoms of being potential harm to
self/others, immediate referral to emergency care is needed.
• The early use of antipsychotics, can decrease risks in patients with schizophrenia or other psychiatric
psychotic disorders.
• The stigma of mental illness & lack of awareness or emphasis on its impact causes challenges for
patients to obtain optimal care .