Psychosis, Acute

Psychosis, Acute is a topic covered in the 5-Minute Emergency Consult.

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  • Disorder of brain function characterized by loss of contact with reality, abnormal perceptions, disorganization of emotions, thought, and behavior
  • Dopamine pathways are strongly implicated
  • May be secondary to psychiatric or medical, nonpsychiatric causes
  • Medical causes of psychosis can be secondary to focal or systemic medical insults, neurologic impairment, or pharmacologic agents


Medical, Nonpsychiatric
  • Neurologic disease:
    • Head injury (history of)
    • Dementias (Alzheimer, Lewy body)
    • Cerebrovascular accident
    • Seizures
    • Space occupying lesions (neoplasm, malignancy, abscesses, cysts)
    • Hydrocephalus
    • Migraines
    • Demyelinating diseases (multiple sclerosis)
    • Neuropsychiatric disorders (Parkinson, Huntington, Wilson disease)
  • Infectious disease:
    • Any focal infection (UTI, PNA, cellulitis)
    • HIV infection
    • Neurosyphilis
    • Lyme disease
    • Encephalitis, meningitis or cerebritis:
      • Bacterial (TB, Lyme)
      • Viral (HSV, CMV, EBV)
      • Fungal (Cryptococcus)
      • Prion diseases
  • Metabolic:
    • Electrolyte imbalance
    • Hypoxia
    • Hypoglycemia
    • Hypercarbia
    • Porphyria
    • Intoxication or withdrawal syndrome
    • Organ failure:
      • Liver (hepatic encephalopathy)
      • Renal
      • Cardiac (CHF, arrhythmias)
  • Endocrine:
    • Thyroid disease
    • Parathyroid disease
    • Cushing syndrome
    • Addison disease
  • Nutritional deficiencies:
    • Niacin
    • Thiamine
    • Vitamin B12 and folate
  • Autoimmune disease:
    • SLE
    • Paraneoplastic syndrome
    • Myasthenia gravis

  • Medications:
    • All medications can cause psychosis
    • Sedative–hypnotics: Benzodiazepines (lorazepam, diazepam, alprazolam), barbiturates (butalbital), other (zolpidem)
    • Anticholinergic and antihistaminergic agents (diphenhydramine, cimetidine)
    • Steroids (prednisone)
    • Antiepileptic agents
    • Antiparkinsonian agents (amantadine, levodopa)
    • Cardiovascular agents (digoxin, reserpine)
    • Anti-infectious medications: Antibiotics (isoniazid, rifampin, fluoroquinolones, TMP/SMX), antivirals (oseltamivir, interferon), antiparasitics (metronidazole)
    • Chemotherapeutic agents (vincristine)
    • Muscle relaxants (dicyclomine, carisoprodol)
  • Substances associated with intoxication:
    • Alcohol
    • Amphetamines
    • Cocaine
    • Opioids
    • Hallucinogens
    • Cannabis
    • Sedative–hypnotics
    • Other: LSD, MDMA, PCP, ketamine
  • Substances associated with withdrawal:
    • Alcohol and sedative–hypnotics
  • Toxins (heavy metals, organophosphates, carbon monoxide)

  • Brief psychotic disorder:
    • Abrupt onset, usually due to psychosocial stressors, lasting <1 mo
  • Delusional disorder:
    • Circumscribed delusions
  • Schizophreniform disorder:
    • Symptoms present 1–6 mo
  • Schizophrenia
  • Schizoaffective disorder
  • Mood disorder with psychotic features
  • Postpartum psychosis

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