Psychosis

Question 1

A 35 year old man presents to the ED stating that people are watching him from parked cars, and that he is frightened to go to the police because he has heard that they want to send him to prison. How would you assess and manage him?

Answer 1

Impression
Features of psychosis with ?delusional thought content. There are many differentials to keep in mind in this presentation. Foremostly are safety considerations for myself, patient, and other staff.

DDX to consider

• FEP
• Drug induced psychosis, drug withdrawal state
• other psychiatric: schizophrenia, schizoaffective disorder, brief psychotic episode
• other affective
• consider a delirium in context of other medical pathology

Goals

• ensure safety of patient and staff, utilise appropriate de-escalation tactics (verbal and pharmacological) in approach patient
• conduct appropriate psych assessment including Hx and MSE, consider role for sectioning under MHA for further treatment and assessment

Question 2

Psychosis - Approach

Answer 2

Initial approach;
- place patient in quiet room away from distractions and noise
Verbal de-escalation:
- offer food + drink
- keep distance, utilise duress alarm, have wards/security inside/outside room
- address any agitation and concerns before conducting assessment of the patient, philosophy of yes, three f’s in approach to initial conversation
- invest in therapeutic alliance with patient

Question 3

Psychosis - History

Answer 3

History

• check patient notes for any previous admissions
• PC: further characterise delusional content, ask about hallucinations (A/V/other), assess their nature (persecutory, reference, grandiose, etc). screen other psych sx such as mood, mania, self-harm/suicidality, depression, anxiety
• Substance use history for comorbid SUD
• past psych history: previous diagnoses, medications, previous admissions, current background
• PMHx
• psychosocial: living circumstances, work, education level

Question 4

Psychosis - Examination

Answer 4

Examination
- MSE
Appearance, behaviour, speech, motor function, mood/affect, thought process, thought content, perception, cognition, insight/judgement
- Vitals
- Cardioresp examination

Question 5

Psychosis - Investigations

Answer 5

Investigations
Given ?FEP, would require full workup with bloods and imaging
- bedside: ECG (QT segment), vitals, Urine drug screen
- bloods: FBC, UEC, LFT, folate/B12, CMP, CRP/ESR, nutritional panel, TFTs
- Imaging: MRI Brain for intracranial lesions

Question 6

Psychosis - Management

Answer 6

Management
- call for community psych/psychiatry involvement and assessment

Safety

• Patient: self-harm/suicide, violence, dependents, risks of exploitation etc
• staff, personally

Setting

• consider inpatient involuntary admission under MHA if significant risk to self or others and mentally ill/disordered
• Complete schedule of patient, and arrange for Form 1 to be completed within 12hrs of scheduling, escort to gazetted room/unit.

Biological

• has a role in the acute setting
• IM Droperidol,. IV haloperidol in acute setting for agitation and psychosis
• consider administration of other antipsychotic agents under guidance of psychiatry
• benzodiazepines for acute agitation (IM midazolam)

Psychological
- therapeutic alliance
- verbal de-escalation in acute setting
- patient education of condition
- 5 evidence based psychological therapies for schizophrenia;
   o CBT
   o vocational training
   o social skills training
   o family based therapy

Social

• NDIS applications
• involvement of social worker regarding community outreach and supports
• community based support groups