Therapeutic Focus

Acute psychotic Disorders

Presenting complaints

Patients may experience;

• hearing voices
  
• strange beliefs or fears
  
• confusion
  
• apprehension
  

Families may ask for help with behaviour changes that cannot be explained, including strange or frightening behaviour (withdrawal, suspiciousness, threats).

Diagnostic features

Recent onset of:

• hallucinations (false or imagined sensations, e.g., hearing voices when on one is around)
  
• delusions (firmly held ideas that are plainly false and not shared by others in the patient's social group, e.g., patients believe they are being poisoned by neighbours, receiving messages from television, or being looked at by others in some special way)
  
• agitation or bizarre behaviour
  
• disorganized or strange speech
  
• extreme and labile emotional states

Differential diagnosis

Physical disorders which can cause psychotic symptoms include;

• epilepsy
  
• intoxication or withdrawl from drugs or alcohol
  
• infectious or febrile illness
  

Refer to card on Delirium - F05 for other potential causes. If psychotic symptoms are recurrent or chronic, also see Chronic psychotic disorders - F20. If symptoms of mania (elevated mode, racing speech or thoughts, exaggerated self-worth) are prominent, the patient may be experiencing a manic episode. See Bipolar disorder F31. If low or sad mood is prominent, also see Depression F23.

Acute psychotic disorder - management guidelines

Essential information for patient and family

• Agitation and strange behaviour are symptoms of mental illness.
  
• Acute episodes often have a good prognosis, but long-term course of the illness is difficult to predict from an acute episode.
  
• Continued treatment may be needed for several months after symptoms resolve.

Advise family about legal issues related to mental health treatment.

Counselling of patient and family

Ensure the safety of the patient and those caring for him/her:

• Family or friends should stay with the patient
  
• Ensure that the patient's basic needs (e.g., food and drinks) are met
  
• Take care not to harm the patient.
  
• Minimize stress and stimulation.
  
• Do not argue with psuyhotic thinking (you may disagree with the patient's beliefs, but do not try to argue that they are wrong).
  
• Avoid confrontation or criticism unless it is necessary to prevent harmful or disruptive behaviour.
  

Agitation which is dangerous to the patient, the family or the community requires hospitalization or close observation is a secure place. If patients refuse treatment, legal measures may be needed

Encourage resumption of normal activities after symptoms improve.


Medication

Antipsychotic medication will reduce psychotic symptoms (e.g. haloperidol 2-5 mg up to three timed a day or chlorpromazine 100-200mg up to three times a day). The dose should be the lowest possible for the relief of symptoms, though patients may require higher doses.

Anti-anxiety medication may also be used in conjunction with neuroleptics to control acute agitation (e.g., lorazepam 1-2mg up to four times a day).

Continue antipsychotic medication for at least three months after symptoms resolve.

Monitor for side effects of medication:

• acute dystonias or spasms may be managed with injectable bensodiazepines or antiparkinsonian drugs
  
• akathisia (severe motor restlessness) may be managed with dosage reduction or beta-blockers
  
• Parkinsonian symptoms (tremor, akinesia) may be managed with oral antiparkinsonian drugs (e.g., biperiden 1 mg up to three times a day).
  

Specialist consultation

If possible, consider consultation for all new cases of psychotic disorder. In cases of severe motor side-effects of the appearance of fever, rigidity, hypertension, stop antipsychotic medication and consider consultation.