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HWN Suggests

Psychosis Mimics: ED Differential Diagnosis and Keys to Management

It’s important to note that psychosis is not always a psychiatric illness per se, but often an indication of an organic illness. Many who have read Susannah Cahalan’s riveting novel, Brain on Fire: My Month of Madness, have developed a new-found apprehension about misdiagnosing psychosis as a symptom of underlying mental disorder (it was misdiagnosed in the ED!). Particularly in emergency medicine, we face the tendency to refer these altered patients to psychiatric services or battle the subconscious assumption that many of these patients created their symptoms (drug abuse, alcoholism).

However, as the adage goes “we cannot make the diagnosis if it’s not on our differential”.

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Articles of Interest

Acute Psychosis In The Emergency Department

The role of the emergency physician, in addition to medically stabilizing and treating acute agitation/psychosis, is to determine whether the patient is experiencing symptoms related to primary psychiatric diagnosis or secondary to a medical illness.

Emergency Room Treatment of Marijuana Psychosis

To illustrate the management of acute complex marijuana intoxication and psychosis, we present a case of a woman requiring prolonged emergency department management after ingestion of edible tetrahydrocannabinol (THC), the active ingredient in marijuana.

Emergency Room Treatment of Psychosis- Lewy Body Dementia

NOTE: Typical antipsychotics (such as haloperidol) and atypical antipsychotics with relatively strong D2 receptor antagonism (such as olanzapine and risperidone) should be avoided due to the risk of neuroleptic malignant syndrome, parkinsonism, somnolence and orthostatic hypotension.

Managing Agitation Associated with Schizophrenia and Bipolar Disorder in the Emergency Setting

Early and excessively aggressive pharmacologic intervention can mask underlying conditions, delaying and impeding accurate diagnosis. However, delays in medication use can allow the agitation to escalate, putting the patient, staff, and others at increased risk of harm.

Treating the acutely psychotic patient

The great majority of presentations with acute psychosis are because of a new psychiatric disease (most often schizophrenia), or an exacerbation of pre-existing psychiatric disease, or are drug induced. Medical causes of psychosis, while uncommon, should be considered when the presentation does not fit the criteria for acute psychiatric disease.

Resources

EPI

The EPI Advanced Practice Project (EPI APP) includes representatives from BC Health Authorities, Ministry of Health, consumer groups, client and family/caregivers and others. The purpose of this EPI APP is to facilitate best practices in EPI service delivery throughout the province.