Acute management and differential diagnosis of first-episode psychosis

Acute Management of the Psychotic Patient

Case history: a 28 year old female we will call Linda presents for acute evaluation. Her primary complaints are anxiety and depression. Past medical history is remarkable for recent diagnosis is elevated liver enzymes with daily alcohol intake since age 11. Patient recently broke off a long term relationship with a boyfriend. On presentation the patient is tangential, with rapid and somewhat incomprehensible speech. She reports hearing the voice of her sister inside her head. Little else is known about this patient on presentation. Management Issues Several questions must be answered immediately about this patient. These will be based upon thorough history and physical taking, though the patient's state of distress will require a directed approach. The following history must be known: . Is psychiatric treatment indicated? . Is hospitalization necessary? . Is the patient competent or a danger to herself or others? Linda will only need to be hospitalized acutely if she reports homicidal or suicidal ideation with intent or plan, or if she lacks sufficient support from family or community to provide her with safety. Linda's degree of agitation represents a possible medical or psychiatric disorder. Her condition is complex and may represent danger to the staff around her. Consideration must be made for medical states (tumor, drug intoxication, withdrawal) or psychiatric problems (acute phase schizophrenia, bipolar disorder). In our short interaction, Linda appears cooperative but she also is delusional and may also have hallucinations. She has a significant disorder of her thought processes, manifested be her sometimes incomprehensible speech. Medically, certain conditions must be ruled out before Linda is transported for psychiatric admission. High on the list of differential diagnosis is head injury, electrolyte imbalance, thyroid disorder, metabolic disturbance, nutritional issues, and toxic substance ingestion. If the history appears clear that Linda has not experience psychosis, hallucination or delusion before, these and other conditions must be ruled out before a psychiatric diagnosis is given. Of primary concern is the safety for Linda and the staff. One person should be encouraged to establish a relationship with Linda in the medical setting, communicating with her but allowing adequate escape distance should her demeanor or threat level change. Linda should be spoken to in a soft, quiet voice in a secure setting. She should be provided choices regarding voluntarily taking medications. Conversation with Linda should be simple and to the point, avoiding prolonged or argumentative conversations.