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CDHB

Acute 'Functional' Psychosis

Acute 'functional' psychoses tend not to be highly differentiated despite the variety of psychiatric syndromes in which they may erupt. Context is vital and history essential to take the diagnosis past 'psychosis' to the perspective of, for example,

• Mania (in bipolar affective disorder).
• Puerperal psychosis.
• Acute schizophrenic episode.
• Major depressive disorder with delusions.
• Borderline personality disorder.

Sometimes when encountering disturbed behaviour in a general hospital, you will not have the benefit of either history or context and will be called upon to help de-escalate a situation.

The symptoms of "psychosis" come from a common pool representative of personal disintegration: impaired reality-testing, delusional thinking, hallucinations (commonly auditory), fear, suspicion, agitation and aggression, leading often to bizarre, reckless, assaultive or even suicidal behaviour.

Clouding of consciousness is not a feature, so that cognitive disorganization, as in delirium, is not prominent, however peculiar the thinking may be.

Management

A combination of antipsychotic and benzodiazepine medications are the mainstay of drug management, whose aim is the restoration of self-control without, if possible, the use of force or physical restraint.

Effective drug treatment should bring early resolution of the most alienating symptoms: hallucinations and delusions, the agitation, the uncooperativeness and raw hostility, the anti-social behaviour, the driven quality of the sleeplessness. Other socially interactive treatment influences then have a chance to repair the less responsive impairments.

Preferred Antipsychotic Drugs

Common side effects of antipsychotic drugs

• Agitation (initially).
• Metabolic syndrome (including weight gain).
• Extrapyramidal side effects: parkinsonism; acute dystonias; dyskinesias. These are less common with these medications than with typical (older) antipsychotics.

  Note: There are fewer extrapyramidal effects with atypical antipsychotics.

• Treatment of extrapyramidal side effects

  Pre-emptive use is not recommended as long as you can respond at short notice (e.g., oculogyric crisis). Nursing staff should be forewarned of the possibility of adverse effects.

  • Benztropine: 1-2 mg (IV, IM or PO).
  • Procyclidine: 5-10 mg (PO).

Some practical management guidelines

• Review early and frequently.
• Once symptoms show some improvement, reduce dosage frequency.
• Write clear instructions to nursing staff about indications for "repeat" dosage.
• The preferred benzodiazepine is lorazepam 1 - 2 mg IM or PO (max daily dose 8 mg).

Topic Code: 1618