Acute Psychosis: A Comprehensive Guide for Nurses

Acute psychosis is a severe mental health condition characterized by a sudden onset of psychotic symptoms, such as hallucinations, delusions, disorganized thinking, and impaired functioning. It is a psychiatric emergency that requires prompt assessment and intervention to prevent harm to the patient and others. Nurses play a critical role in the early recognition, management, and support of individuals experiencing acute psychosis.

Definition

Acute psychosis is a state of mental disturbance in which there is a loss of contact with reality. It can be a symptom of various psychiatric disorders, including schizophrenia, schizoaffective disorder, bipolar disorder, severe depression, or substance-induced psychosis. The condition may develop rapidly over days or weeks and can be transient or the first episode of a chronic mental illness.

Etiology and Risk Factors

1. Psychiatric Disorders

Schizophrenia Spectrum Disorders

Bipolar Disorder

Major Depressive Disorder with Psychotic Features

Schizoaffective Disorder

2. Substance Use

Substance-Induced Psychosis: Use or withdrawal from substances such as alcohol, amphetamines, cocaine, cannabis, hallucinogens, or synthetic drugs (e.g., synthetic cannabinoids, bath salts).

3. Medical Conditions

Neurological Disorders: Brain tumors, epilepsy, encephalitis, dementia.

Metabolic Disorders: Hypoglycemia, electrolyte imbalances, hepatic or renal failure.

Infections: HIV/AIDS, syphilis, Lyme disease.

Autoimmune Diseases: Systemic lupus erythematosus.

4. Environmental and Psychosocial Factors

Severe Stress or Trauma

Sleep Deprivation

Social Isolation

5. Genetic Predisposition

Family history of psychotic disorders increases the risk.

Clinical Presentation

Positive Symptoms (Excess or distortion of normal functions)

Hallucinations

Auditory: Hearing voices or sounds that are not present.

Visual: Seeing things that are not there.

Tactile: Sensations of being touched.

Olfactory and Gustatory: Smelling or tasting things without a source.

Delusions

Persecutory: Belief of being plotted against.

Grandiose: Exaggerated sense of importance or power.

Referential: Belief that neutral events have personal significance.

Somatic: False beliefs about bodily functions.

Disorganized Thinking

Incoherent Speech: Word salad, tangentiality, loose associations.

Thought Blocking: Sudden interruption in speech or thought.

Disorganized or Catatonic Behavior

Agitation or Hyperactivity

Unpredictable Actions

Catatonia: Motor immobility or excessive motor activity.

Negative Symptoms (Reduction or loss of normal functions)

Affective Flattening: Limited emotional expression.

Alogia: Poverty of speech.

Anhedonia: Inability to experience pleasure.

Avolition: Lack of motivation.

Cognitive Symptoms

Impaired Attention

Memory Deficits

Difficulty with Executive Functions

Diagnosis

Assessment

Comprehensive Psychiatric Evaluation

History of Present Illness: Onset, duration, and progression of symptoms.

Past Psychiatric History: Previous episodes, hospitalizations.

Substance Use History: Type, amount, duration of substance use.

Medical History: Underlying medical conditions.

Family History: Psychiatric illnesses in relatives.

Mental Status Examination (MSE): Appearance, behavior, mood, thought processes, perceptions.

Physical Examination

Assess for signs of medical conditions that may cause psychosis.

Laboratory Tests

Complete Blood Count (CBC)

Electrolyte Panel

Liver and Renal Function Tests

Thyroid Function Tests

Drug Screen: Urine or blood toxicology.

Infectious Disease Screening: If indicated.

Imaging Studies

Computed Tomography (CT) Scan

Magnetic Resonance Imaging (MRI)

To rule out structural brain abnormalities.

Diagnostic Criteria

Based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for specific psychotic disorders.

Management of Acute Psychosis

Goals

Ensure safety of the patient and others.

Reduce psychotic symptoms.

Identify and treat underlying causes.

Prevent recurrence and promote recovery.

1. Immediate Interventions

Safety Measures

Environment: Provide a calm, non-stimulating setting.

Supervision: Continuous observation if the patient is a danger to self or others.

Restraints: Use the least restrictive means necessary, following legal and ethical guidelines.

De-escalation Techniques

Use verbal calming strategies.

Establish rapport and trust.

2. Pharmacological Treatment

Antipsychotic Medications

Typical Antipsychotics (First-generation)

Haloperidol

Effective for acute agitation and psychosis.

Monitor for extrapyramidal side effects (EPS) and tardive dyskinesia.

Chlorpromazine

Atypical Antipsychotics (Second-generation)

Risperidone

Olanzapine

Quetiapine

Ziprasidone

Aripiprazole

Lower risk of EPS.

Monitor for metabolic side effects (weight gain, hyperglycemia, dyslipidemia).

Administration

Oral, intramuscular (IM), or intravenous (IV) routes depending on the patient's condition.

Adjunct Medications

Benzodiazepines (e.g., Lorazepam)

For agitation, anxiety, or insomnia.

Use cautiously due to risk of sedation and respiratory depression.

3. Treatment of Underlying Causes

Substance-Induced Psychosis

Manage withdrawal symptoms.

Provide supportive care.

Medical Conditions

Address metabolic imbalances, infections, or organ dysfunctions.

4. Psychosocial Interventions

Psychoeducation

Educate the patient and family about the condition and treatment plan.

Supportive Therapy

Provide reassurance and emotional support.

Family Involvement

Engage family members in care planning and support.

Nursing Interventions

1. Assessment and Monitoring

Vital Signs

Monitor temperature, pulse, blood pressure, and respiratory rate.

Mental Status

Regularly assess for changes in thought processes, perceptions, and behavior.

Medication Effects

Observe for therapeutic effects and adverse reactions.

Safety Checks

Ensure the environment is free from harmful objects.

2. Communication Techniques

Use Clear and Simple Language

Avoid complex instructions.

Establish Trust

Be consistent, honest, and respectful.

Active Listening

Validate the patient's feelings without reinforcing delusions.

3. Environment Management

Calm and Structured Setting

Minimize noise and overstimulation.

Routine

Establish a predictable daily schedule.

4. Medication Administration

Adherence Support

Educate on the importance of taking medications as prescribed.

Manage Side Effects

Monitor for EPS, metabolic syndrome, and other adverse effects.

5. Patient and Family Education

Understanding Psychosis

Explain symptoms, course, and prognosis.

Coping Strategies

Teach stress reduction techniques.

Relapse Prevention

Identify early warning signs.

Complications

1. Risk of Harm

Suicide

Increased risk due to command hallucinations or severe depression.

Violence

Potential aggression towards others.

2. Medication Side Effects

Extrapyramidal Symptoms

Dystonia, akathisia, Parkinsonism.

Tardive Dyskinesia

Involuntary movements, often irreversible.

Neuroleptic Malignant Syndrome

Rare but life-threatening reaction.

Metabolic Syndrome

Weight gain, diabetes, hyperlipidemia.

3. Social and Occupational Impairment

Difficulty maintaining relationships or employment.

Ethical and Legal Considerations

Informed Consent

Assess capacity to consent; involve legal guardians if necessary.

Confidentiality

Maintain privacy unless disclosure is necessary to prevent harm.

Involuntary Treatment

Understand laws regarding involuntary hospitalization and treatment.

Discharge Planning and Follow-Up

Aftercare Services

Arrange outpatient psychiatric care.

Community Resources

Connect with support groups and social services.

Medication Management

Ensure continuity of pharmacotherapy.

Relapse Prevention Plan

Develop strategies to manage stress and adhere to treatment.