This document defines psychosis and its common manifestations such as delusions, hallucinations, disorganized speech and behavior, and negative symptoms. It then discusses potential differential diagnoses for psychotic manifestations including various psychiatric disorders, substance use, medical conditions, and medication side effects. The key points of assessment include evaluating the patient's history, conducting a physical and neurological exam, and assessing risk. Initial evaluations may include labs, imaging, and toxicology screens to help determine underlying causes. Management involves making a provisional diagnosis, assessing comorbidities and risk, providing stabilization if needed, and determining next steps such as admission, referral, or discharge.

1. Mohamed Sedky
QMHH
March 2019

2. What is psychosis

3. Psychotic Manifestations
delusions
 Persecutory
 Grandiosity
 Infidelity
 Erotomanic
 Religious
 Reference
 Guilt
 Nihilistic
 Poverty
 Somatic
 Delusional perception
 Thought control (withdrawal, insertion, broadcasting)
 Delusions of Passivity (affect, impulse, volition, somatic)

4. Psychotic Manifestations
Hallucinations
 Auditory
 Visual
 Olfactory
 Gustatory
 Somatic

5. Psychotic Manifestations
Disorganized speech
Incoherence
loose association
Derailment
Fragmentation
Perseveration
Verbigeration
Neologisms
Jargon
Word salad
Flight of ideas
Thought blocking

6. Psychotic Manifestations
Disorganized Behaviour
Bizarre/Purposeless actions
Inappropriate laughing or crying
Inappropriate dressing
disheveled appearance
Unprovoked agitation
Inappropriate sexual behaviors
A decline in overall daily functioning
Catatonic Behaviors: peculiar movements (bizarre postures/stereotyped
movements/mannerisms/grimacing), echopraxia, echolalia, negativism, mutism,
posturing , catatonic stupor, catatonic excitement

7. Psychotic Manifestations
Negative Symptoms
Affective flattening
Avolition/apathy
Alogia
Social withdrawal
Difficulty concentrating
lack of spontaneity
Lack of motivation and drive
A sudden decline in self-care

8. Differential Diagnosis

9. Differential Diagnosis of
psychotic manifestations
Primary psychiatric Disorders:
 Brief Psychotic Disorder
 Schizophrenia
 Delusional Disorder
 Schizoaffective Disorder
 Psychosis in Major Depression
 Psychosis in Bipolar I Disorder

10. Differential Diagnosis of
psychotic manifestations
Substance induced psychosis (drug intoxication
or withdrawal):
 Amphetamines
 Cannabis
 Alcohol
 Cocaine
 Opiods
 Inhalants
 Ketamine
 Sedative/hypnotic

11. Differential Diagnosis of
psychotic manifestations
Other psychiatric conditions:
personality disorder
• Borderline personality disorder
• Paranoid personality disorder
• Schizoid Personality Disorder
• Schizotypal personality disorder
Obsessive compulsive disorder
Panic disorder
Autism Spectrum Disorder
Psychotic symptoms with dissociative disorders

12. Differential Diagnosis of
psychotic manifestations
Delirium:
 Perceptual distortions, illusions, and
hallucinations—characteristically visual.
 There may be poorly developed paranoid
delusions.
 Speech may be rambling, incoherent, and
thought disordered.
 Psychomotor agitation.
 Onset of clinical features is rapid with
fluctuations in severity over minutes and
hours (even back to apparent normality).

13. Differential Diagnosis of
psychotic manifestations
Dementia:
 Hallucinations and delusions
often paranoid (20–40%) and
poorly systematized.
Catastrophic reaction.
History of personality change,
forgetfulness, social withdrawal,
lability of affect, disinhibition,
‘silliness’, diminished self-care,
apathy, fatigue, and deteriorating
executive functioning.

14. Differential Diagnosis of
psychotic manifestations
Medical etiologies:
 Neurological (epilepsy, head injury, brain tumour,
encephalitis, e.g. HSV, HIV, neurosyphilis, brain
abscess, CVA).
 Endocrine (hyper/hypothyroidism, Cushing’s,
hyperparathyroidism, Addison’s disease).
 Metabolic (uraemia, electrolyte disturbance,
porphyria).
 Autoimmune (MS, SLE).

15. Differential Diagnosis of
psychotic manifestations
Medication side effect:
 Antiparkinsonian medications
 Corticosteroids
 Antihypertensives
 Digoxin
 Interferon
 Ketamine
 Psychostimulants (methylphenidate, amphetamine)
 Medication overdose
 Medication toxicity due to drug-drug interactions

16. Assessment

17. Key points in assessment
 Psychiatric history
 Patient's demographics
 Substance use history
 Full medical history: medical conditions, medications
 Family history

18. Key points in assessment
 The nature of hallucinations
 Time course of illness
 Presence of fluctuations
 Vital signs
 Physical examination
 Neurological examination

19. Risk Assessment
Risk of harm to self Risk of harm to others

20. Initial Evaluation
 Toxicology screen
 Complete blood count
 Complete metabolic panel-
renal/hepatic function, electrolytes,
glucose, cholesterol, and
triglycerides.
 Thyroid function tests
 Urine analysis
 ECG
 Pregnancy test
 Serology: HIV status, Hepatitis B &
C screen
 Emergency brain imaging is usually
not required unless organic brain
insult is suspected.

21. Management
 Provisional diagnosis
 Comorbidity
 Risk assessment
 Rapid tranquilization
 Admission
 Referral
 Discharge