11.2 Psychosis and Delirium

Psychosis

Approximately 3 percent of the people in the United States experience psychosis at some point in their lives. About 100,000 adolescents and young adults in the US experience their first episode of psychosis each year.^[1]

The term psychosis describes conditions where there is a loss of contact with reality. When a person experiences psychosis, their thoughts and perceptions are disturbed, and the individual has difficulty understanding what is real and what is not real. Symptoms of psychosis include delusions and hallucinations, where the client is seeing, hearing, or experiencing other sensations and experiences that aren’t real. See Figure 11.1.^[2] for artwork titled Hallucinations. Other symptoms of psychosis include incoherent or nonsensical speech and behavior that is inappropriate for the situation. A person experiencing a psychotic episode may also experience depression, anxiety, sleep problems, social withdrawal, lack of motivation, and overall difficulty functioning. When someone experiences this condition, it is referred to as a psychotic episode.^[3]

Psychosis can be a symptom of various mental illnesses, such as schizophrenia, bipolar disorder, severe depression, or severe anxiety, but there are also other potential causes. Sleep deprivation, medical conditions such as hyperglycemia and hyperthyroidism, side effects of some prescription medications, and use of alcohol or other drugs can also cause psychotic symptoms.^[4] 

Early Signs of Psychosis

Typically, a person will show changes in their behavior before psychosis develops. Behavioral warning signs for psychosis include the following^[5]:

• Drop in grades or worsening job performance
• New trouble thinking clearly or concentrating
• Suspiciousness; paranoid ideas or uneasiness with others
• Withdrawing socially; spending a lot more time alone than usual
• Unusual, bizarre new ideas
• Strange feelings or having no feelings at all
• Decline in self-care or personal hygiene
• Difficulty telling reality from fantasy
• Confused speech or trouble communicating

Symptoms of a Psychotic Episode

See the following box for signs and symptoms of a psychotic episode according to the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) by the American Psychiatric Association.

A brief psychotic episode is defined by a psychotic event lasting at least one day but less than one month, with an eventual return to previous level of functioning. It does not include a culturally sanctioned response, such as a person’s response to the death of a loved one. The disturbance is not better explained by a major depressive disorder or bipolar disorder with psychotic features, another psychotic disorder, or the physiological effects of a substance or a medical condition. The mental health provider may specify if the symptoms are in response to significant stressors (i.e., significant events to anyone experiencing similar circumstances in the individual’s culture) or has a peripartum onset (i.e., during pregnancy or within four weeks of delivery).^[7]

Review information about delusions, hallucinations, and disorganized speech in the “Application of the Nursing Process in Mental Health Care” chapter.

Treatment of Psychosis

Treatment for psychosis is based on its cause. For example, if psychosis is caused by a medical condition, side effects of medication, or withdrawal from a substance, it will resolve as these conditions are treated. If psychosis is a symptom of mental illness, treatment typically includes a combination of antipsychotic medicines and psychological therapies. Read more about the treatment of psychosis associated with schizophrenia in the “Schizophrenia” section of this chapter.

Delirium

Psychosis caused by medical issues is often referred to as delirium. Delirium is a mental state in which the client becomes temporarily confused, disoriented, and not able to think or remember clearly. It usually starts suddenly and can indicate the onset of a life-threatening medical condition. Delirium resolves as the underlying condition is effectively treated. There are many common causes of delirium, including the following^[8],[9]:

• Dehydration and electrolyte imbalances
• Dementia
• Hospitalization, especially in intensive care
• Intoxication or withdrawal from alcohol or drugs
• Kidney or liver failure
• Medications, such as sedatives, opioids, anesthesia, antihistamines, anticholinergics, antidepressants, antipsychotics, or anticonvulsants
• Metabolic disorders, such as diabetic ketoacidosis (DKA)
• Serious infections, such as urinary tract infections, pneumonia, and influenza
• Severe pain
• Sleep deprivation

The symptoms of delirium usually start suddenly, over a few hours or a few days, and they often come and go. The most common symptoms are as follows^[10]:

• Changes in alertness (usually more alert in the morning, less at night)
• Changing levels of consciousness
• Confusion
• Disorganized thinking or talking in a way that doesn’t make sense
• Disrupted sleep patterns or sleepiness
• Emotional changes: anger, agitation, depression, irritability, or overexcitement
• Hallucinations and delusions
• Incontinence
• Memory problems, especially with short-term memory
• Trouble concentrating

The symptoms of delirium can often be managed with the following interventions^[11]:

• Making sure the room is quiet and well-lit
• Having clocks and calendars within view
• Inviting family members to spend time in the room
• Ensuring hearing aids and glasses are worn
• Allowing for undisrupted sleep when possible
• Getting patients up and out of bed when possible
• Controlling pain with pain relievers (unless the pain medication is causing the psychosis)
• Administering prescribed medications to distressed clients at risk to themselves or to others to calm and settle them, such as haloperidol (However, administer medications with caution because oversedation can worsen delirium.)
• Avoiding the use of restraints