First presentation psychosis

Question 1

“A 19 year old girl is taken to her GP by her mother following an outburst of aggressive behaviour and accusations that her parents are “controlling her”. How would you assess and manage?

2020 stem: Psychotic man in ED. 2 prev admission - for suicidal something and drugs. Formulate a plan for the ED nurse. What do you want to know on history? How do you want to manage this patient?”

Answer 1

Impression
Given aggressive outburst and delusions of control, concerned about a first psychotic episode.

Would want to rule out drug induced psychosis, and other organic causes of this presentation.

Ddx:

• drug induced psychosis
• Other psychotic disorder: schizophrenia, shizophreniform, schizoaffective, delusional disorder
• Mood disorder: Bipolar, psychotic depression
• substance use disorder

Question 2

First presentation psychosis - Approach

Answer 2

Approach

1) Safety: consider appropriate location for assessment: security, quiet room, low stimulus environment, duress, etc.
2) Patient may require de-escalation strategies including chemical sedation to reduce aggression
3) may require admission under MHA

Question 3

First presentation psychosis - Assessment

Answer 3

Assessment
Psych History
- PC: sx of psychosis (delusions,
- screen for mania (DIGFAST), depression, anxiety, violence, substance use disorder
- risk assessment (suicide, harm to others)
- Rest of Psych history

MSE

• all abnormalities can be observed in examination. IN particular, paying attention to;
• Thought content/form -> formal thought disorder, delusions
• Perception: Visual and Auditory hallucinations
• Insight + judgement
• Mood/affect

Question 4

First presentation psychosis - Investigations

Answer 4

Investigations
Are necessary in FPP in order to rule out organic causes

• Bedside: ECG, anthropometric, urine drug screen
• Bloods: FBC, UEC, LFT, TFT, CMP, ESR/CRP, Lipid panel, consider ANA/ENA etc
• Imaging: MRI Brain, other imaging as required
• Other: consider LP

Question 5

First presentation psychosis - Acute management

Answer 5

Management:
Important for FPP to be managed emergently, as association between patient outcomes and period of time spent in psychosis - psychosis is toxic to the brain.

Acute management

1) Antipsychotic medication
- start on low dose to avoid side-effects
- consider depot medication if adherence unlikely

2) benzodiazepines for agitation (diazepam, midazolam IM if aggressive)

3) Psychological therapy - usually limited in acute setting
- psychoeducation
- counselling

4) manage any substance withdrawal as appropriate
- alcohol: thiamine, benzo’s, AWS
- opiates: supportive

Question 6

FPP - ongoing management

Answer 6

Ongoing Management
Pyschological
- counselling
- psychoeducation
- CBT + cognitive remediation
- family intervention

Biological

• Antipsychotic treatment for ideally 6-12 months, at least 3 months
• monitor for adverse effects (metabolic, hormonal, etc)

Safety-netting

• case management
• regular psych review/ follow-up
• social support: financial and employment assistance