(from Best Practice Report on Acute Psychosis)

 

History

 

An acutely psychotic patient may be agitated, incoherent, and unable to give a history.   In the initial encounter with the patient, the physician may be required to respond immediately to the patient's agitated state without a clear understanding of the nature of the illness. An agitated or potentially violent patient should not be interviewed without the availability of staff trained to deal with violence.  If the patient can be interviewed, do so in a quiet room, if possible, to diminish noise, distractions, and emotional distress. 

 

Ask about the immediate circumstances prior the patient's coming for treatment.  Inquire about changes in the patient s usual mental, emotional, and physical state, and the circumstances of the patient's life leading up to the present encounter.  Determine what brought the patient to treatment at this particular moment?

 

Look for indications that the precipitating cause of the psychosis may be an underlying medical illness.  One of the first judgments to be made is whether the psychosis results from an illness primarily requiring psychiatric treatment, such as schizophrenia or bipolar illness, or whether it results from brain dysfunction due to an organic cause, such as intrinsic brain pathology or medical disease occurring outside of the CNS. 

 

The sudden onset of psychiatric symptoms in a person who functioned well up to that time should raise the suspicion of underlying medical illness.   Psychotic symptoms appearing for the first time in a patient over 30 years of age should also suggest this possibility, especially if the patient's level of consciousness or cognitive abilities are impaired.  Even if a patient has a long history of mental illness, an abrupt change in the character of the illness and its symptomatology may indicate an underlying medical etiology.

 

Follow standard medical format in obtaining a history of the psychotic episode: Chief complaint, history of present illness, past psychiatric and medical history, and family psychiatric and medical history.  The form of the medical history does not change in the case of a patient with psychiatric illness; however, greater emphasis is placed on mental and emotional experiences, such as hallucinations, feelings of elation or depression, or loss of memory.  It may not always be possible to obtain a complete history or to do a thorough interview with an acutely psychotic patient.  The use of other sources of information is often necessary to make a differential diagnosis.  Establish a more complete history in subsequent interviews, and refine or modify the diagnosis as additional information is gathered.