A 26-year-old male is brought into your ED by police for aggressive and bizarre behavior. He has no history of acting this way, but he has been having some more minor behavior changes the past few weeks according to family.  

Being the astute EM doctor you are, you try and come up with an explanation for his behavior. First time schizophrenic episode? Bipolar with mania? Drugs or alcohol? You were taught by Doctor O’Connor well, so you even threw on some medical causes; hypoglycemia, hyponatremia, postictal state.  

My goal with this post is to help to identify some of the much less common medical causes of psychosis but ones you should think about if you see certain features. I’m going to start with some that usually are caught earlier on in life and then do a few in the elderly. 

What Is Psychosis? 

Psychosis is broken down into 4 different features: hallucinations, delusions, disorganized thoughts and negative symptoms. Hallucinations are defined as sensing things that are not there. Delusions are things that could be true but are not actually. Examples being “I’m the president of the world”. Technically based upon something that could be real but is not. Disorganized thinking is the tendency that people have to have trouble concentrating or following a singular thought without tangents. Negative symptoms are ones that cause patients to act withdrawn and uninteractive. They are often harder to recognize as they are not as strange usually.  

Knowing these features can help you to identify actual psychosis in patients rather than patients who are just being combative but not psychotic. It will help us get to the next step which is to help figure out what is causing the psychosis. 

Wilson Disease 

Wilson disease is caused by a defect in the ceruloplasmin protein that binds and transports copper around the body. It causes copper to build up in places that it shouldn’t, including the brain and other neurological tissue. The majority of patients are diagnosed between the ages of 5 and 35 with mean being 13. The disease presents with liver disease in 18 to 84% of patients, neurological disease in 18 to 73% of patients and psychiatric symptoms in 10 to 100% of patients. The most common signs are gait disturbances, dysarthria, dystonia and tremor.  However, psychiatric symptoms may precede the recognition of hepatic or neurologic Wilson disease by a significant period. The most common behavioral and psychiatric symptoms include depression (reported in 20 to 30 percent of patients with Wilson disease), personality change, incongruous behavior, and irritability. 

To suspect a patient would be suffering from Wilson Disease, you should try and suss out if there are any neurological symptoms in your psychiatric patients. If you see features such as the above-mentioned dysarthria, or gait disturbances you should be suspicious. If you see Kaiser-Fleischer rings, copper deposits around the iris, this is almost diagnostic for Wilson Disease.  

Syphilis  

Syphilis is largely a disease of the past with the protections in place and easy treatment of the day. When it is caught it is usually in the earlier stages, 1 or 2. But it can progress to stage 3 and when it does, it presents with psychiatric symptoms as well as neurological. Stage 3 syphilis symptoms are described as a general paresis. In a study of 116 patients with general paresis in China, dementia, personality change, abnormal behavior, and emotional problems were the most common findings. On initial evaluation, neurosyphilis was not suspected in 36 percent of patients, which delayed the diagnosis for 1 to 24 months.  Physical exam findings to look out for are dysarthria, facial and limb hypotonia, intention tremors of the face, tongue, and hands, and reflex abnormalities. Pupillary abnormalities, including Argyll-Robertson pupils, may also be seen. General paresis usually develops 10 to 25 years after infection, but it can occur as early as two years after infection. You can test for this by ordering an RPR and some titers for confirmatory testing if RPR Is positive.  

Hyperammonemia  

This comes up usually in people who are known to be cirrhotic or otherwise long term alcoholics but can sometimes be considered in younger patients. In this case it would be due to an inborn error of metabolism, most commonly Ornithine Transcarbamylase Deficiency. Suspect this if you see the classic asterixis on exam. You can test for this with an ammonia level  

Niacin Deficiency 

Getting less common as we go along, this can present with dermatitis, diarrhea and dementia which can take the form of psychosis in younger population. Less common because our diet is usually filled with sources of niacin but in homeless or drug dependent patients, over time this can develop.   

Lewy Body Dementia 

In elderly people with chronic tremors, Parkinson disease is often the answer, and this can eventually lead to bouts of psychosis. If the psychosis, almost always visual hallucinations, precedes the motor dysfunction, think Lewy Body Dementia.  

I hope this review has led you to think about medical causes of psychosis and where to start with working them up in the Emergency department.

  

Dr Maxwell Brown DO

Sources 

Uptodate 

Tintinallis Emergency Medicine