Psychosis has been defined as a “fundamental derangement of the mind characterized by defective or lost contact with reality.”¹ The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V),² defines psychotic disorders as those that include abnormalities in one or more of five domains: hallucinations, delusions, disorganized or abnormal motor behavior, disorganized thinking, and negative symptoms. The hallmark of these psychoses, schizophrenia, has a worldwide prevalence of 0.5% to 1%³ and affects approximately 2.4 million adults in the United States.⁴ Considered one of the leading causes of chronic incapacity, the term schizophrenia, meaning “split mind,” was coined by Eugene Bleuler in 1911.⁵ The economic burden of schizophrenia in the United States in 2002 was estimated at $62.7 billion⁶ and typically accounts for 1.5% to 3% of the total national healthcare expenditure, with a high incidence of ED utilization.⁷

The assessment of the psychotic patient presenting to the ED can be challenging, because patients may be agitated, combative, uncooperative, or unable to provide any history. The goals of evaluation are multiple. First, minimize any potential harm to the patient and ensure the safety of the ED staff and other patients. In the case of an aggressive or violent patient, this may require the use of verbal de-escalation techniques or physical or chemical restraints. Second, assess for any coexisting or confounding medical or traumatic conditions. Emergency physicians are gatekeepers to the psychiatric world, because once the patient is funneled into the psychiatric treatment realm, organic conditions may become more difficult to identify and treat. Psychiatric conditions contribute to increased mortality from comorbid medical conditions as compared to the general population.⁸ Finally, aim to optimize the treatment of the patient’s underlying psychiatric illness, either by connecting him or her with the appropriate inpatient or outpatient resources, or, when possible, by contacting his or her psychiatrist.

Both environmental and genetic factors contribute to the schizophrenia spectrum of disorders. The incidence of schizophrenia is higher in those growing up in urban areas⁹ and in certain minority ethnic groups,¹⁰ and the disorders have been linked to a spectrum of risk alleles. There is also overlap between the alleles associated with schizophrenia and those associated with other disorders such as autism and bipolar disorder.¹¹

Traditionally, the dopamine hypothesis, wherein excessive dopamine leads to the pathophysiology of schizophrenia, has been the dominant theory.¹² Now, it is thought that dopamine acts as the common final pathway of a wide variety of predisposing factors, either environmental, genetic, or both, that lead to the disease. Other neurotransmitters, such as glutamate and adenosine, may also collaborate with dopamine to give rise to the entire picture of schizophrenia.¹³

HISTORY

Features of psychoses include hallucinations, delusions, disorganized thinking, and negative symptoms.

A hallucination is an “apparent, often strong subjective perception of an external object or event when no such stimulus or situation is present.”² Although hallucinations may occur in any sensory modality, they are most commonly auditory in schizophrenia and other psychotic disorders. Typically these are experienced as voices distinct from the individual’s own thoughts. Not all hallucinations are considered to be pathologic; they may be a normal part of certain religious and cultural experiences.

A delusion is “a false belief or wrong judgment, sometimes associated with hallucinations, held with conviction despite evidence to the contrary.”¹⁴ Delusions may be classified based on various themes, including grandiose (i.e., “when an individual believes that he or she has exceptional abilities, wealth, or fame”), persecutory, erotomanic (i.e., “when an individual believes falsely that another person is in love with him or her”), and referential (i.e., “belief that certain gestures, comments, environmental cues, and so forth are directed at oneself”). Delusions are considered bizarre if they are clearly implausible. In the ED, a nonbizarre delusion may be difficult to distinguish from a strongly held idea.²

Typically, disorganized thinking is inferred from a patient’s speech. Commonly encountered patterns may include derailment or loose associations, wherein the individual switches from one topic to another; tangentiality, wherein answers to questions may be unrelated or loosely related; and word salad, wherein the individual’s speech becomes so disorganized that it becomes nearly incomprehensible.²

Negative symptoms associated with psychotic disorders include avolition (decreased motivation), diminished emotional expression, anhedonia (decreased ability to experience pleasure), asociality (decreased interest in social interaction), and alogia (decreased speech).

PHYSICAL EXAMINATION

Aside from grossly disorganized or abnormal motor behavior (discussed below), there are no specific physical findings associated with the psychotic disorders. The goal of physical examination is the exclusion of coexisting medical or traumatic conditions. For agitated patients, be particularly vigilant to assess for any self-inflicted injuries, environmental injuries such as frostbite, or injuries occurring during the restraint process.

Grossly disorganized or abnormal motor behavior may take on various forms, although it is likely most familiar to emergency practitioners as unpredicTable agitation. Catatonia, a “marked decrease in reactivity to the environment” is not frequently encountered in the ED. Catatonic features may range from negativism, which is a resistance to instructions, to maintenance of a rigid or inappropriate posture, to complete lack of motor or verbal response. Catatonic behavior may occur in association with a variety of psychiatric and medical conditions.²

Psychotic symptoms may be caused by numerous medical conditions, including infections such as encephalitis, meningitis, or cystitis; CNS conditions such as stroke, seizure, Parkinson’s disease,¹⁵ or brain tumor; and metabolic derangements such as hypoglycemia or hepatic encephalopathy. Additionally, various medications and illicit substances may give rise to psychotic symptoms (Table 290-1).^16,17,18,19

The DSM-V, delineates specific diagnostic criteria for the schizophrenia spectrum and other psychotic disorders (see discussion below). However, such granular distinctions are typically not necessary or relevant for emergency assessment and treatment. Rather than making a specific psychiatric diagnosis, the ED provider’s focus should be on emergency treatment and stabilization, identification of comorbid conditions, and appropriate disposition. Assignment of a specific diagnosis should be left to the purview of those with specialized psychiatric training. Diagnostic testing is directed by the history and physical examination. Routine laboratory testing for otherwise sTable and cooperative psychiatric patients is of low yield and need not be performed in most cases. Similarly, urine toxicologic screening rarely affects ED management and need not be routinely obtained.²⁰

Many psychotic patients presenting to the ED have been previously diagnosed with a psychiatric condition. In such cases, determine whether there has been an acute change from the patient’s baseline and whether the current presentation is confounded by another condition that requires medical treatment. In cases where the patient is unable to aid with providing history, use other resources, including past medical records, medication lists, family members, and case workers.

For patients with new-onset psychosis, the ED is a common point of first contact with the healthcare system.²¹ It is then incumbent on the provider to determine whether the patient’s psychosis is the by-product of an acute medical condition, a reaction to a medication or illicit substance, or truly the new onset of a primary psychiatric illness. Newly symptomatic patients often warrant a more extensive medical evaluation than those with known underlying psychotic disorders.

Psychotic patients may present anywhere along a spectrum ranging from high functioning to completely disabled. Guide disposition decisions by considerations of patient safety and optimization of treatment. Patients thought to be violent, at risk of self-harm, or unable to care for themselves typically require emergent psychiatric evaluation and possible inpatient psychiatric care. Patients with new-onset psychosis (not thought to be due to a medical cause) or those with worsening of underlying psychotic symptoms should have psychiatric consultation in the ED, if available, or be transferred to a psychiatric facility. Patients with known psychoses under apparent good control may be referred for outpatient management. Ideally, such referrals should be made in consultation with the patient’s treating psychiatric provider.

Finally, patients with psychosis secondary to a medical condition or those with comorbid illness should be managed accordingly. Give special consideration to a patient’s functional level and ability to manage the medical condition as an outpatient. For example, a schizophrenic patient with an infection that might otherwise be treated with oral antibiotics at home might benefit from hospitalization if there is doubt about the patient’s ability to comply with treatment and follow-up instructions.