Rosen & Barkin's 5-Minute Emergency Medicine Consult (634 page)

Criteria of the
Diagnostic and Statistical Manual of Mental Disorders IV
(
DSM-IV
) require the presence of at least 2 of the following symptoms for more than 6 mo:

• Delusions (fixed, false beliefs):
  
  • Bizarre, paranoid, or grandiose
    
  • Often persecutory, religious, or somatic content
    
• Hallucinations:
  
  • Commonly auditory or visual but may involve any sensory modality
    
• Thought disorder:
  
  • Disorganized speech ranging from odd, idiosyncratic logic to incoherence
    
• Grossly disorganized or catatonic behavior
  
• Negative symptoms:
  
  • Apathy and amotivation
    
  • Flat affect
    
  • Social isolation
    
  • Anhedonia
    

• Complete general and neurologic exam including vital signs and mental status exam
  
• Screen for psychosis:
  
  • Delusions:
    
    • “Do you feel anyone is trying to harm you or that you are being followed?”
      
    • “Is anyone trying to send you messages, steal, control, or block your thinking?”
      
  • Hallucinations:
    
    • “Do you ever see or hear things that other people cannot see or hear?”
      
    • “Do you ever hear voices telling you to do things such as to harm yourself or others?”
      
• Evaluate potential dangerousness to self or others:
  
  • Screen for past violence or self-injury
    
  • Content of psychotic symptoms should be explored to assess safety
    
• Patient history and medication compliance may be unreliable. Obtain collateral history from additional sources:
  
  • Friends and family
    
  • Treaters (PCP, therapist, psychiatrist)
    
  • Pharmacy
    
• Evaluate for affective psychosis (bipolar, major depression, or schizoaffective disorder)
  
• Evaluate for delirium or dementia
  
  • Schizophrenia does not affect orientation.
    
• Assess for drug-induced psychosis (see “Psychosis, Acute”)
  
• Psychosis due to medical etiology should be ruled out
  

• Toxicology screen
  
• Electrolytes, BUN, creatinine, glucose, calcium
  
• CBC with differential
  
• TSH
  
• Urinalysis
  

Consider head imaging for new onset psychosis of undetermined etiology or new onset neurologic symptoms

EKG to monitor QT

• Delirium
  
• Drug-induced psychosis
  
• Psychosis secondary to general medical conditions such as TLE, MS, LBD
  
• Bipolar disorder
  
• Major depression with psychotic features
  
• Schizoaffective disorder:
  
  • Schizophrenia with prominent depressive and/or manic symptoms during psychosis
    
• Delusional disorder
  
• Schizotypal personality
  
• Brief psychotic episode:
  
  • Similar symptoms, duration of <1 mo
    
• Schizophreniform disorder:
  
  • Similar symptoms, duration between 1 and 6 mo
    

TREATMENT

• Patients can display unpredictable and violent behavior toward themselves and others
  
• Patients may require police presence and/or restraints to maintain safety
  
• Local laws vary as they apply to involuntary restraint
  

• Safety of healthcare workers and patient is paramount; security presence may be required
  
• Behavioral interventions should be 1st line:
  
  • Provide a calm, containing environment
    
  • Potentially dangerous items should be removed from the patient’s room
    
  • Use a reassuring voice and calm demeanor to set boundaries and verbally redirect the patient
    
• If safety is a concern, patient needs to be under constant observation and physical or chemical restraints may be necessary
  
• Acute agitation may be treated with haloperidol PO/IV/IM which can be augmented with lorazepam PO/IV/IM:
  
  • Encourage voluntary PO meds prior to IM administration
    
  • Other IM antipsychotics include olanzapine, chlorpromazine (monitor orthostatics), ziprasidone (monitor QT), and aripiprazole
    
  • IM olanzapine should not be combined with IV benzodiazepines as this increases risk of cardiopulmonary collapse
    

• Psychiatric consultation in cases of decompensated schizophrenia
  
• Antipsychotic medications are the mainstay of treatment
  
• High-potency typical antipsychotic agents:
  
  • Associated with less QT prolongation
    
  • Higher propensity for extrapyramidal symptoms:
    
    • Dystonia
      
    • Parkinsonism
      
    • Akathisia
      
    • Tardive dyskinesia
      
  • IV haloperidol associated with fewer extrapyramidal symptoms than PO/IM
    
• Low-potency typical antipsychotics:
  
  • Higher risk of QT prolongation
    
  • Fewer extrapyramidal symptoms
    
  • More sedating
    
  • Orthostatic hypotension (must monitor)
    
  • Anticholinergic side effects
    
  • Lower seizure threshold
    
• Atypical antipsychotic agents:
  
  • Better tolerated with less EPS
    
  • Associated with metabolic syndrome and weight gain
    
  • Can cause orthostatic hypotension
    
  • Nearly all antipsychotics increase QT:
    
    • More likely (ziprasidone)
      
    • Less likely (aripiprazole)
      
  • Clozapine is the only antipsychotic that is clearly more effective for reducing psychotic symptoms and suicide risk:
    
    • Requires close monitoring of WBCs due to agranulocytosis
      
    • Highly sedating, hypotensive, lowers seizure threshold
      
    • Can cause QT prolongation
      
• Long-acting antipsychotic preparations (given q2–6wk) include:
  
  • Fluphenazine decanoate
    
  • Haloperidol decanoate
    
  • Olanzapine depot (Relprevv)
    
  • Paliperidone palmitate (Sustenna)
    
  • Risperidone microspheres (Consta)
    
• If a high-potency conventional antipsychotic agent is initiated, patients younger than age 40 can be started on benztropine (Cogentin) 2 mg BID for 10 days to reduce the risk of dystonic reactions
  

• Typical antipsychotics (1st generation):
  
  • High potency:
    
    • Haloperidol 0.5–100 mg/d. Acute agitation 2.5–10 mg PO/IV/IM. Repeat q20–60min as needed
      
    • Fluphenazine 10 mg/d
      
    • Thiothixene 1–30 mg/d
      
  • Medium potency:
    
    • Perphenazine 2–24 mg/d
      
    • Trifluroperazine 1–20 mg/d
      
  • Low potency:
    
    • Chlorpromazine 0–200 mg/d in 3 div. doses
      
    • Loxapine 5–100 mg/d
      
    • Thioridazine 50–800 mg/d in 2–3 div. doses
      
• Atypical antipsychotics (2nd generation):
  
  • Aripiprazole 5–30 mg/d
    
  • Asenapine 5–20 mg/d (SL)
    
  • Clozapine 12.5–900 mg/d
    
  • Iloperidone 1–24 mg/d
    
  • Lurasidone 20–160 mg/d
    
  • Olanzapine 5–20 mg/d
    
  • Paliperidone 6–12 mg/d
    
  • Quetiapine 25–800 mg/d
    
  • Risperidone 1–16 mg/d
    
  • Ziprasidone 20–160 mg/d
    
• Benzodiazepines:
  
  • Lorazepam (Ativan) 0.5–2 mg per dose augments antipsychotic for acute agitation
    

Black box warning: Elderly patients with dementia-related psychoses treated with antipsychotic drugs are at increased risk of death.

FOLLOW-UP

• Admit to inpatient psychiatric hospital, if patient is medically stable and:
  
  • Is a danger to self or others
    
  • Is gravely disabled and unable to care for himself due to psychosis
    
  • Has new-onset psychosis and medical etiology has been ruled out
    
• Prior to transfer to psychiatric facility, patient must have acute medical and surgical issues addressed
  
• Criteria for involuntary psychiatric hospitalization vary by state
  

• Patient is not a danger to self or others and is able to perform activities of daily living
  
• Psychiatric follow-up is arranged
  
• Psychotic symptoms may persist at time of discharge
  

• Outpatient psychopharmacologic follow-up should occur within 1 wk of discharge
  
• Patients taking antipsychotics (especially atypicals) should be monitored for QT prolongation and for obesity and related metabolic syndromes
  
• Adjunctive cognitive behavioral therapy and other psychosocial treatments can help patients manage psychotic symptoms and improve medication compliance
  
• Discuss smoking cessation and referral:
  
  • 50–80% of patients with schizophrenia smoke tobacco
    

• Visual, olfactory, gustatory, or tactile hallucinations should prompt medical workup for secondary causes of psychosis, as should atypical age of onset (>30 yr old)
  
• Early treatment with antipsychotic medications and social interventions have consistently been associated with better outcomes in schizophrenia
  
• Avoid using IM olanzapine with IV benzodiazepines as this increases risk for cardiopulmonary collapse
  
• Patients who recently started antipsychotics who present with fever, rigidity, autonomic instability, and mental status changes should be assessed for neuroleptic malignant syndrome
  

• American Psychiatric Association.
  Diagnostic and statistical manual of mental disorders
  . 4th ed. Text Revision (DMS-IV-TR), American Psychiatric Association, Washington, DC; 2000.
  
• Buckley P, Citrome L, Nichita C, et al. Psychopharmacology of aggression in schizophrenia.
  Schizophr Bull.
  2011;37:930–936.
  
• Freudenreich O, Holt DJ, Cather C, et al. The evaluation and management of patients with first-episode schizophrenia: A selective, clinical review of diagnosis, treatment, and prognosis.
  Harv Rev Psychiatry
  . 2007;15:189–211.
  
• van Os J, Kapur S.
  Schizophrenia. Lancet.
  2009;374:635–645.
  

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