Following the initial triage and assessment of the psychotic patient, the pa-tient should be searched and placed in a safe environment. The full psychiat-ric evaluation can then begin. During the interview, the same basic safety precautions that apply to all psychiatric patients should be closely followed.
Foreign-Language or Hearing-Impaired Psychotic Patients As with any psychiatric interview, a thorough examination must be con-ducted in a language the patient can understand. Patients for whom English is not their preferred language should be offered the opportunity to conduct the interview with a translator or using a translator phone, even if they appear to speak English adequately (Sabin 1975). Conducting an interview with a psychotic patient via translator can be a very challenging process. Live trans-lators, if available, are always preferable to translation by phone. Translators should be informed at the outset that they are being called on to help in a
psy-chiatric evaluation. Translators inexperienced in interviewing psychotic pa-tients should be encouraged prior to the interview to translate verbatim, and to resist the temptation to interpret the patient’s statements or to try to syn-thesize them into a cohesive form; disorganized speech is an important psy-chotic symptom that may go overlooked under such circumstances (Marcos 1979). Often, translators assisting with evaluation of a psychotic patient will report that they are having some trouble with the translation or that some-thing about the patient’s speech or vocabulary is difficult to understand. This may be an important clue that the patient is communicating in an unusual way; the clinician should ask the translator to be as specific as possible about what the patient is saying. As is true in any psychiatric evaluation, the clini-cian intent on making a determination of psychosis should not neglect to as-sess affective symptoms (Sabin 1975).
Patients who are deaf or hard of hearing should be asked what their pre-ferred means of communication is and should be accommodated. There is a difference, not only in mode of communication but in culture, history, pre-sentation, and sense of identity, between the patient who is deaf, particularly one who has been deaf since childhood, and the patient who is hard of hear-ing. When using a sign language interpreter, the clinician should always look and speak directly to the patient, not to the interpreter. American Sign Lan-guage uses a different syntax and grammar than spoken English, which makes the evaluation of psychosis in the deaf patient a particular challenge, because a literal translation of a deaf person’s statements can sound concrete to a hear-ing person, when in fact the statement is perfectly normal. Unlike a foreign language translator, a proficient and experienced sign language interpreter must interpret some of the patient’s statements for the clinician, and likewise must interpret for the patient the many words that do not exist in American Sign Language into their nearest comprehensible meaning. Writing, although on occasion unavoidable in an emergency, is not an appropriate substitute for signing with a deaf person (Iezzoni et al. 2004). In either foreign language or sign language interpretation, it is not appropriate to use a patient’s family member or friend as interpreter; such interpretation is apt to be less accurate than that provided by an uninterested third party and is a violation of patient privacy.
The Interview
The evaluation of the psychotic patient should include, as much as the patient will tolerate, a complete history and mental status examination. Within the mental status examination, more time should be spent eliciting psychotic symptoms from the patient. Wording of questions to obtain the necessary in-formation in a nonthreatening manner that is validating to the patient is crit-ical to establishing the therapeutic alliance. Important areas of focus in the mental status examination of the psychotic patient include abstraction, char-acterization of thought process and content, and characterizing internal pre-occupation.
Patients should be asked about hallucinations in the least stigmatizing manner possible, especially patients experiencing a first psychotic episode.
When hallucinations are present, it is important to ask whether the patient hears one or more than one voice, whether voices talk to the patient or about the patient, and what the content of the hallucinations is. Patients should be questioned about command auditory hallucinations. If a patient reports com-mand auditory hallucinations, it is of critical importance to obtain a detailed history of the nature of the commands and assess whether the patient has ever acted on commands from auditory hallucinations.
Questions about delusions should cover the range of common delusional types: persecutory, somatic, religious, and grandiose. When inquiring about delusional thoughts, the interviewer should tread carefully, because any fragile rapport he or she has managed to build with a paranoid or frankly delusional patient may be negated if the clinician appears to doubt or challenge a pa-tient’s firmly held belief; on the other hand, it is never acceptable practice to collude with a patient’s delusions. In the case of somatic delusions, a patient presenting with a somatic complaint must receive a thorough and appropriate medical workup, even if the patient has a primary psychotic disorder, and par-ticularly if there is no documentation of such a workup having been done in the past.
Collateral Sources of Information
The importance of collateral information from other sources, such as friends, family, providers, and outside observers, in the evaluation of the psychotic pa-tient in the emergency setting cannot be overestimated. Papa-tients presenting
with psychotic symptoms may be paranoid and refuse to give correct or com-plete information, or may be too disorganized to give such information. Health Insurance Portability and Accountability Act (HIPAA; U.S. Department of Health and Human Services 2003) regulations allow a clinician to contact outside sources of information in the case of an emergency, so that the patient who lacks capacity to give consent can receive emergency care. Other poten-tial sources of (or clues to) collateral information include the patient’s own property and medical records. If the patient will permit a search, his or her cellular phone, wallet, and other items might provide important information that the patient may not be able to recall.
Case Example (continued)
Collateral information obtained from a nearby Veterans Hospital revealed that Mr. S was human immunodeficiency virus (HIV) positive, his last CD4 lymphocyte count was 232, and he had been treated with atovaquone and the combination drug Atripla. When asked about this, Mr. S reported noncom-pliance with his medications. The hospital’s records also indicated a history of a parotid mass that had not yet been fully worked up. Although their notes indicated that Mr. S had a history of alcohol dependence, there was no record of any previous psychiatric treatment. Vital signs on arrival to the hospital were within normal limits, and Mr. S was not noted to have any alcohol on his breath.
Differential Diagnosis
After completing the psychiatric evaluation, the clinician must form a differ-ential diagnosis. For all patients presenting to the psychiatric emergency de-partment, it is generally helpful to think about differential diagnosis in terms of several broad categories into which symptoms might fit: 1) medical condi-tions, 2) substance-induced condicondi-tions, 3) psychotic disorders, 4) mood dis-orders, 5) anxiety disdis-orders, and 6) other miscellaneous conditions.
Medical Conditions
Although medical issues are often the least frequent cause of symptoms in pa-tients who have already been triaged to psychiatry, papa-tients should be exam-ined for medical conditions first both because a medical issue presents a potentially quickly reversible cause of symptoms and because missing a
med-ical condition can cause dire consequences. This situation is clearly illustrated by the clinical case of Mr. S. The clinician should not rush to conclude that a patient who appears psychotic has a primary psychiatric condition.
Table 6–1 presents a list, albeit not exhaustive, of medical conditions that can present with psychotic symptoms, along with the symptoms that they can commonly cause and accompanying signs. Often these symptoms include de-lirium, a syndrome characterized by waxing and waning mental status that can also be accompanied by psychotic symptoms, including disorganization, hallucinations (particularly visual hallucinations), and false beliefs that are usually not fixed.
Given all the possible medical causes of psychotic symptoms, it is difficult to determine the appropriate medical workup for the psychotic patient (par-ticularly given that most of these conditions are rare and tests will likely be low yield). Regardless of psychiatric history, every patient who presents with psychotic symptoms should at minimum have a complete blood count, a com-prehensive metabolic profile, thyroid-stimulating hormone test, and syphilis screening. Given its prevalence and the added benefit as a public health mea-sure, HIV testing should also be encouraged. A more extensive workup should be considered for patients with new-onset psychotic symptoms: imag-ing, preferably magnetic resonance imagimag-ing, should strongly be considered to rule out tumors and other intracranial lesions as the cause of psychotic symp-toms, and electroencephalography should be considered to rule out seizures (particularly temporal lobe epilepsy). Further tests should be ordered if his-tory or the results of initial testing are suspicious for a rare medical cause. For instance, a psychotic patient who is found to have elevated liver function tests might warrant further workup for Wilson’s disease, including an ophthalmo-logical exam looking for Kayser-Fleischer rings and serum ceruloplasmin.
Similarly, a patient with a history of brief psychotic episodes associated with neuropathy and abdominal pain should have urine sent during an episode (checking for uroporphyrin, porphobilinogen, and aminolevulinic acid) to rule out acute intermittent porphyria. Treatment for psychosis secondary to a general medical condition should be directed toward addressing the underly-ing medical condition and is usually best accomplished on a medical unit with psychiatric consultation.
Substance-Induced Conditions
A variety of substances can cause psychotic symptoms, during either the intox-ication phase or the withdrawal phase. Table 6–2 lists some of the substances commonly encountered in the emergency setting and their accompanying symptoms. Substance use can also predispose patients to falls and other acci-dents with consequent head trauma, which can then present with psychiatric symptoms. It is important not to fall into the trap of incorrectly attributing these symptoms to the substance use, because missing a head injury can lead to dire consequences for the patient. Patients with substance abuse who present with new-onset psychotic symptoms should be examined for evidence of head trauma and, if present, head imaging should be obtained.
All patients presenting with psychotic symptoms in the emergency de-partment should be screened for substance use with urine or serum toxicol-ogy. Treatment for substance-induced psychosis usually involves maintaining the patient’s safety in a psychiatric setting with supportive interventions un-til the symptoms resolve. An exception to this is delirium tremens, which re-quires aggressive medical management (often in an intensive care unit) to prevent seizures, aspiration, and death. Despite the fact that patients with substance-induced psychoses often do not have an underlying psychotic illness, they can benefit from antipsychotics and benzodiazepines on an as-needed basis during the episode to address their symptoms, particularly if agitation is prominent.
Psychotic Disorders
Perhaps the most obvious diagnoses to consider when a patient presents with psychotic symptoms in the psychiatric emergency setting are the primary psy-chotic disorders. These include schizophrenia, schizoaffective disorder, schizophreniform disorder, and brief psychotic episode. These diagnoses are distinguished from one another by history obtained from the patient and col-lateral information about time course, presence or absence of mood symp-toms, and presence or absence of stressors. The following is a brief review of the criteria for each diagnosis (APA 2000):
• Schizophrenia. At least 6 months of symptoms, and at least 1 month of meeting two of the following symptoms: delusions, hallucinations,
disor-Table 6–1. Medical conditions that can present with
Delirium; physical stigmata of underlying cause of electrolyte imbalance (e.g., enlarged parotid glands, dental disease in bulimia)
Hepatic encephalopathy Causes: acute or chronic liver failure
Delirium; asterixis; jaundice
Brain tumors Hallucinations and/or delusions accompanied by headache; disorganization not usually present if tumor is focal
Infections (both systemic and CNS)
Delirium; elevated temperature; elevated WBC;
focal signs of infection (e.g., nuchal rigidity)
HIV Mania; dementia (featuring prominent
psychomotor retardation); opportunistic infections can cause delirium or focal symptoms Wilson’s disease Bizarre behavior; psychosis; motor symptoms; liver
and kidney function abnormalities Huntington’s disease Personality changes; depression; psychosis;
choreiform movements; family history usually present
Acute intermittent porphyria Psychosis; abdominal pain; neuropathy; autonomic dysfunction
Tertiary syphilis Psychosis; dementia; ataxia; Argyll Robertson pupils Hyperthyroidism or
hypothyroidism
Mood and psychotic symptoms; physical symptoms of each syndrome (e.g., heat or cold intolerance, hair loss, weight loss/gain)
Seizures Interictal or postictal psychosis; hyperreligiosity;
“viscous” or “sticky” style of interaction; auditory hallucinations in temporal lobe epilepsy Dementia Visual hallucinations (particularly in Lewy body
dementia); paranoid ideation (most typically that people are stealing from them)
ganized speech, grossly disorganized or catatonic behavior, or negative symptoms.
• Schizoaffective disorder. At least 6 months of symptoms, including both mood and psychotic symptoms, with psychotic symptoms present for at least 2 weeks in the absence of mood symptoms at some point during the illness.
• Schizophreniform disorder. At least 1 month but less than 6 months of psy-chotic symptoms.
• Brief psychotic episode. Psychotic symptoms appear and resolve fully in less than 1 month; symptoms are often caused by (and it is prognostically bet-ter if there is) the presence of an acute stressor.
Treatment for primary psychotic disorders usually involves the use of anti-psychotic agents combined with supportive psychotherapy.
Mood Disorders
Both manic and major depressive episodes can present with psychotic fea-tures. Given that mood disorders are much more common than primary psy-chotic disorders, and that the treatment and prognosis are different for patients with mood disorders with psychotic features than for patients with primary psy-chotic disorders, all patients presenting with psypsy-chotic symptoms should be evaluated closely, both during the interview and in the gathering of collateral information, for the presence of mood symptoms. Psychotic symptoms that are present during mood episodes are usually mood congruent (e.g., the manic patient may have grandiose delusions, whereas the depressed patient Medications
Examples: steroids, interferon, levetiracetam (Keppra), dopamine agonists
Psychosis is usually temporally related to when the patient began taking the medication; would be classified as substance-induced psychosis by DSM-IV-TR
Note. CNS=central nervous system; DSM-IV-TR=Diagnostic and Statistical Manu-al of MentManu-al Disorders, 4th Edition, Text Revision (American Psychiatric Association 2000); WBC=white blood count.
Table 6–1. Medical conditions that can present with psychosis (continued)
Condition Signs and symptoms
may have negativistic delusions, such as that his or her organs are rotting).
Treatment for mood disorders with psychotic features involves pharmacolog-ical treatment, both for the mood symptoms and for the psychotic symptoms, as well as psychotherapy.
Anxiety Disorders
Severe presentations of some anxiety disorders may appear to be psychosis, and this possibility should be considered in patients presenting to the emer-Table 6–2. Substances that can cause psychosis
Substance Signs and symptoms
Alcohol Intoxication: agitation may appear psychotic Withdrawal: hallucinations with alcoholic
hallucinosis; hallucinations and delirium with delirium tremens
Amphetamines Intoxication: psychosis similar to that seen with cocaine but often prolonged (3–5 days), dilated pupils; often accompanied by stigmata of chronic amphetamine use (e.g., anorexia, poor dentition)
Cannabis Intoxication: paranoid ideation; if severe, drug may have been laced with other substances (e.g., PCP)
Cocaine Intoxication: disorganization, manic symptoms, delusions, hallucinations (including tactile), dilated pupils; lasts for hours after use Withdrawal: depressed mood, hallucinations,
somnolence and social withdrawal; beginning hours after use and lasting 24–72 hours Hallucinogens (LSD, psilocybin
mushrooms)
Intoxication: vivid visual hallucinations, dissociative symptoms; occasions of recurrence of symptoms of intoxication (“flashbacks”) can occur months or years after use
PCP Intoxication: hallucinations, delusions,
unpredictable violence; symptoms wax and wane and can last 3–5 days; associated with hyperacusis and nystagmus
Note. LSD =lysergic acid diethylamide; PCP =phencyclidine.
gency department. Some patients with obsessive-compulsive disorder can hold their obsessive thoughts so rigidly or engage in such bizarre rituals as to appear psychotic. Patients who are in the midst of reexperiencing episodes of posttraumatic stress disorder (particularly when intoxication is also involved) can also appear psychotic. This phenomenon highlights the importance of obtaining a full psychiatric review of symptoms during the interview, because the treatment for these disorders will be very different than for primary psy-chotic disorders.
Miscellaneous Conditions
Several other conditions should be considered in the differential diagnosis for patients presenting to the emergency department with psychotic symptoms.
Patients with borderline personality disorder, as well as other cluster B person-ality disorders, can develop micropsychotic episodes, particularly in the context of acute stressors. Patients with dissociative disorder can appear disorganized and psychotic.
Although it should always be a diagnosis of exclusion, malingered psycho-sis is unfortunately not at all uncommon in the psychiatric emergency setting.
In general, malingering should be considered in patients who have clear mo-tives for doing so (as in patients under arrest) and exhibit inconsistencies in their history and mental status examination, or are very vague in their descrip-tions of their symptoms. Patients who report dangerous symptoms that are inconsistent with their affect, behavior, and thought process are suspect (e.g., a patient who appears cheerful in the waiting area but subsequently reports to the doctor, “I’m hearing voices telling me to kill myself and others”). The more detail the psychiatrist presses for during the interview, the more difficult it will become for a malingering patient to keep his or her story straight (Resnick 1999). When available, medical records from within the same insti-tution should be examined; a patient with a history of malingering or with a pattern of brief inpatient admissions from which the patient frequently signs out against medical advice, would be added evidence against a patient sus-pected of malingering.