🩺 Acute Psychosis

Acute psychosis is a clinical syndrome characterised by a loss of contact with reality, involving hallucinations, delusions, and thought disorder. It is a medical emergency that requires urgent assessment to manage risks. In the UK, patients presenting with a first episode of psychosis are typically referred to Early Intervention in Psychosis (EIP) teams. Management involves a combination of antipsychotic medication, psychological support (CBTp), and social interventions, often initiated under the framework of the Mental Health Act if the patient lacks insight and presents a risk.

The history should focus on the onset, duration, and nature of symptoms, specifically looking for prodromal features like social withdrawal or declining school/work performance. Clarify the nature of the delusions (fixed, false beliefs) and hallucinations. A detailed drug history is essential, focusing on cannabis, amphetamines, and cocaine. It is vital to enquire about risk to self through command hallucinations and risk to others stemming from paranoid delusions. Collateral history from family or friends is often the most reliable source of information.

Commonly involves a comprehensive Mental State Examination (MSE) assessing Appearance and Behaviour (suspiciousness, agitation), Speech (pressure or poverty), Mood (incongruent), and Thought (delusions of reference, persecution, or grandeur; thought broadcast/withdrawal). Perception assessment focuses on hallucinations, most commonly auditory 'third-person' voices. Insight is often severely impaired. Physical examination should look for signs of drug use (needle marks) or neurological deficits.

Schizophrenia, Schizoaffective disorder, Drug-induced psychosis, Delirium, Bipolar disorder (manic episode), Anti-NMDA receptor encephalitis.

Command hallucinations (voices telling the patient to harm themselves or others). Signs of neuroleptic malignant syndrome (rigidity, fever, autonomic instability) if already on medication. Catatonia (immobility, waxy flexibility). Severe self-neglect. Paranoid delusions involving specific high-risk individuals.

Routine screening includes U&Es, LFTs, TFTs, CRP, and calcium to exclude metabolic disturbances. A urine toxicology screen is mandatory to identify substance-induced psychosis. If the presentation is atypical (e.g., sudden onset, older age, or neurological signs), a CT/MRI head and potentially an EEG should be performed. In younger patients with rapid onset, consider Anti-NMDA receptor encephalitis and test for autoantibodies. The ECG is required before starting many antipsychotics due to QTc prolongation risks.

In a first-presentation of psychosis, 'organic' causes must be excluded before a primary psychiatric diagnosis is made—specifically illicit drug use (cannabis, stimulants) and encephalitis. If a patient presents with fluctuating levels of consciousness or new-onset visual hallucinations (rather than auditory), think of delirium or organic brain insult. Early Intervention in Psychosis (EIP) services provide multidisciplinary support that significantly improves long-term outcomes. Rapid tranquillisation protocols should only be used after verbal de-escalation has failed.

Fits within the 'Psychosis' and 'Severe Mental Illness' sections of the MLA. Awareness of the Mental Health Act (MHA) 1983 (amended 2007) is crucial, particularly Sections 2, 3, and 5(2). Students must recognise the metabolic side effects of atypical antipsychotics, including weight gain and dyslipidaemia.