5-152
Subjective: Symptoms
Patient often unaware of symptoms; in delirium, history of recent injury, illness
Paranoia: Unreasonable suspiciousness; feelings of persecution, being single out or watched; includes
feelings of grandiosity
Hallucinations: False sensory perceptions not associated with real external stimuli; delirious patients often
have tactile and visual hallucinations; psychotic patients more often have auditory hallucinations
Delusions: False belief, based on incorrect inference about external reality; not consistent with patient’s
intelligence and cultural background; cannot be corrected with reasoning
Focused History: How long has this been going on? (Delirium has a rapid onset of hours to days; psychosis
takes days to weeks.) Do the symptoms change at night? (Delirium is often worse at night; psychosis is
not so variable.)
Objective: Signs
Using Basic Tools: Autonomic instability (delirium) versus normal vital signs (psychosis), assess for head
trauma or occult injury (differential); diffuse hyperreflexia (delirium).
Mental Status Exam:
- Alertness: Diminished (delirium); normal or increased (psychosis); not responsive to external stimuli
(both) - Orientation: Disoriented to person, place, time, situation or all (delirium); oriented (psychosis) but answers
may be contrived and bizarre - Activity: Agitated, especially in evenings (delirium); catatonia—purposeless movements or rigid posturing
with waxy flexibility (psychosis) - Speech: Slurred words or difficult to comprehend (delirium); disorganized and uses made up words called
neologisms (psychosis) - Thought Content: Delusions, paranoid ideation, simplified thinking (psychosis)
- Thought Processes: Difficult to follow because of loose associations or flight of ideas; thoughts often
derail or stop abruptly (psychosis) - Mood: Disorganized (psychosis)
- Affect: Inappropriate to situation or stated mood; often blunted or flat (psychosis)
- Cognition: Impaired memory, attention tasks (both)
- Judgment: Impaired (both)
Using Advanced Tools: Evidence of medical illness in delirium; ↑WBC, ↓HCT, etc.
Assessment:
Differential Diagnosis
Delirium - orientation is generally impaired; identify underlying medical problem and treat it.
Psychosis - orientation generally preserved; identify underlying medical problem and treat it.
Substance Abuse - alcohol withdrawal, PCP, amphetamine, cocaine intoxication appear psychotic
Seizure Disorder - temporal lobe epilepsy (often with herpes encephalitis) can appear psychotic.
Head Injury - may cause delirium; obtain history from other unit members.
Mental Disorders principally associated with psychosis:
Schizophreniform disorder and schizophrenia - ages 15-25 men, 20-35 women
Bipolar Disorder, manic with psychotic features - 3rd and 4th decade, sometimes earlier
Major Depressive Disorder, severe with psychotic features - more common in an older population
Brief Psychotic Disorder - may or may not have an identifiable precipitant; begins and resolves within 30
days, often with supportive measures alone.
(Identify the presence of a mental disorder first; do not worry too much about what type it is.)
Plan:
Treatment
- Calm the patient to protect him and others around him. Psychotic and delirious patients may pose a
danger to self or others simply through agitation, reckless behavior or inappropriate activities. For both use:
a. Benzodiazepines (diazepam 5-10 mg po or IM, lorazepam 2 mg po, IM or IV).
b. Neuroleptics (haloperidol 2-5 mg IM or po) can settle an agitated patient. If haloperdol