Clinical manifestations, differential diagnosis, and initial management of psychosis in adults
- Stephen Marder, MD
Stephen Marder, MD
- Section Editor — Psychotic Disorders
- Professor of Psychiatry
- Semel Institute of Neuroscience at UCLA
- Michael Davis, MD, PhD
Michael Davis, MD, PhD
- Assistant Professor of Psychiatry & Behavioral Sciences
- Baylor College of Medicine
Psychosis is a condition of the mind broadly defined as a loss of contact with reality. It is estimated that 13 to 23 percent of people experience psychotic symptoms at some point in their lifetime, and 1 to 4 percent will meet criteria for a psychotic disorder [1,2].
Psychotic symptoms can increase patients’ risk for harming themselves or others or being unable to meet their basic needs. Most clinicians will encounter patients with psychosis and will thus benefit from knowing how to recognize psychotic symptoms and make appropriate initial evaluation and management decisions. Other clinicians, particularly mental health specialists, will conduct a more thorough patient assessment, consider the patient’s differential diagnosis, and determine the patient’s diagnosis to guide long-term treatment.
This topic will characterize different types of psychotic symptoms, provide guidance for formulating a differential diagnosis, and suggest initial evaluation and management practices. Issues related to antipsychotic medications, the treatment of specific disorders, and psychosocial interventions are discussed separately. (See "Second-generation antipsychotic medications: Pharmacology, administration, and side effects" and "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Schizophrenia in adults: Epidemiology and pathogenesis" and "Schizophrenia in adults: Clinical manifestations, course, assessment, and diagnosis" and "Pharmacotherapy for schizophrenia: Long-acting injectable antipsychotic drugs" and "Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment" and "Psychosocial interventions for co-occurring schizophrenia and substance use disorder" and "Evaluation and management of treatment-resistant schizophrenia" and "Anxiety in schizophrenia" and "Depression in schizophrenia" and "Pharmacotherapy for schizophrenia: Side effect management" and "Brief psychotic disorder" and "Psychosocial interventions for schizophrenia".)
Psychosis can present with a wide variety of signs and symptoms , which are described below.
Delusions — Delusions are defined as strongly held false beliefs that are not typical of the patient’s cultural or religious background. They can be categorized as bizarre or non-bizarre based on their plausibility (eg, a belief that family members have been replaced by body-doubles is bizarre and a belief that a spouse is having an affair is non-bizarre). Frequently encountered types of delusions include:
- van Os J, Hanssen M, Bijl RV, Vollebergh W. Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Arch Gen Psychiatry 2001; 58:663.
- Perälä J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry 2007; 64:19.
- Sadock BJ, Sadock VA, Kaplan HI. Kaplan and Sadock's Comprehensive Textbook of Psychiatry, Lippincott Williams & Wilkins, 2009. Vol 1.
- Sheitman BB, Lee H, Strous R, Lieberman JA. The evaluation and treatment of first-episode psychosis. Schizophr Bull 1997; 23:653.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
- Fiorentini A, Volonteri LS, Dragogna F, et al. Substance-induced psychoses: a critical review of the literature. Curr Drug Abuse Rev 2011; 4:228.
- Webster R, Holroyd S. Prevalence of psychotic symptoms in delirium. Psychosomatics 2000; 41:519.
- Leentjens AF, Rundell J, Rummans T, et al. Delirium: An evidence-based medicine (EBM) monograph for psychosomatic medicine practice, comissioned by the Academy of Psychosomatic Medicine (APM) and the European Association of Consultation Liaison Psychiatry and Psychosomatics (EACLPP). J Psychosom Res 2012; 73:149.
- Jellinger KA. Cerebral correlates of psychotic syndromes in neurodegenerative diseases. J Cell Mol Med 2012; 16:995.
- Freudenreich O, Schulz SC, Goff DC. Initial medical work-up of first-episode psychosis: a conceptual review. Early Interv Psychiatry 2009; 3:10.
- First MB. DSM-5 Handbook of Differential Diagnosis, American Psychiatric Publishing, Arlington, VA 2013.
- Yildiz A, Vieta E, Leucht S, Baldessarini RJ. Efficacy of antimanic treatments: meta-analysis of randomized, controlled trials. Neuropsychopharmacology 2011; 36:375.
- Wijkstra J, Lijmer J, Burger H, et al. Pharmacological treatment for psychotic depression. Cochrane Database Syst Rev 2013; :CD004044.
- Wang HR, Woo YS, Bahk WM. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci 2013; 67:323.
- Frieling H, Hillemacher T, Ziegenbein M, et al. Treating dopamimetic psychosis in Parkinson's disease: structured review and meta-analysis. Eur Neuropsychopharmacol 2007; 17:165.
- Katz I, de Deyn PP, Mintzer J, et al. The efficacy and safety of risperidone in the treatment of psychosis of Alzheimer's disease and mixed dementia: a meta-analysis of 4 placebo-controlled clinical trials. Int J Geriatr Psychiatry 2007; 22:475.
- Cañas F. Management of agitation in the acute psychotic patient--efficacy without excessive sedation. Eur Neuropsychopharmacol 2007; 17 Suppl 2:S108.
- Ringbäck Weitoft G, Berglund M, Lindström EA, et al. Mortality, attempted suicide, re-hospitalisation and prescription refill for clozapine and other antipsychotics in Sweden-a register-based study. Pharmacoepidemiol Drug Saf 2014; 23:290.
- Buchanan RW, Kreyenbuhl J, Kelly DL, et al. The 2009 schizophrenia PORT psychopharmacological treatment recommendations and summary statements. Schizophr Bull 2010; 36:71.
- CLINICAL MANIFESTATIONS
- Thought disorganization
- DIFFERENTIAL DIAGNOSIS
- Primary psychiatric illnesses
- Substance-induced psychoses
- Psychoses associated with medical or neurological conditions
- DIAGNOSTIC EVALUATION
- Mental status examination
- Common medical workup
- Additional tests to consider based on other evidence
- INITIAL MANAGEMENT
- Consultation or referral to a psychiatrist
- Voluntary versus involuntary treatment
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS