"ORGANIC CAUSES MUST BE CONSIDERED AND EXCLUDED BEFORE THE PSYCHOSIS IS ATTRIBUTED TO A PRIMARY PSYCHOTIC DISORDER."
Source: BMJ Evidence Centre (Best Practice) and reprinted on the above linked blog titled:
A careful medical history should be taken to identify possible
organic causes of the psychosis. This should be considered even if the
patient has a known primary psychotic disorder, as organic and
psychiatric causes can co-exist. Key features of the history include:
- History of recent or past head trauma:
a recent head trauma should raise suspicion of a subdural haematoma.
Previous head trauma may cause a seizure disorder and increases the risk
- Recent seizures or a known history of a seizure disorder: it is
important to establish the timing of psychosis in relation to seizure
activity (postictal, ictal, and interictal).
- Neurological symptoms: key symptoms that should prompt suspicion of
organic CNS disease include new-onset headaches or changes in headache
pattern, focal weakness or sensory loss, visual disturbance (double
vision or partial vision loss), and speech deficits, including
dysarthrias and aphasias. Abnormal body movements, memory loss, and
tremor in older patients should prompt suspicion of dementia.
Fluctuating consciousness suggests that delirium is present.
- Recreational drug use: any recent use of alcohol, cocaine, cannabis,
amphetamines, or phencyclidine should prompt suspicion of drug-induced
psychosis. A history of heavy alcohol, benzodiazepine, or barbiturate
use followed by abrupt cessation should raise suspicion of a withdrawal
syndrome, especially if the onset is abrupt.
- Prescription medications: common offending medications include
anticholinergic drugs, dopamine agonists, corticosteroids, adrenergic
drugs (stimulants, propranolol, clonidine), and thyroid hormones. It is
important to establish when any new drugs were started, or when doses
were changed, and how the timing relates to the onset of symptoms.
- OTC medications: common offending drugs include dextromethorphan, antihistamines, and medications containing phenylpropanolamine, especially if used chronically or at very high doses.
- Exposure to heavy metals:
if the main water supply is from a well or the patient has any
occupation or hobby that involves chemical or heavy metal exposure,
heavy metal poisoning should be suspected. Physical symptoms of lead toxicity
include nausea, vomiting, diarrhoea, anaemia, weakness in limbs, and
convulsions. Common symptoms of arsenic poisoning are vomiting,
diarrhoea, kidney failure, pigmentation of soles and palms,
hypersalivation, and progressive blindness. Mercury toxicity presents
with symptoms of metallic taste, hypersalivation, gingivitis, tremors,
and blushing. Psychosis with mercury toxicity is rare.
- Exposure to organophosphates: a history of the use of pesticides
(especially in farm workers) should prompt suspicion of organophosphate
poisoning. The diagnosis is clinical. There is often an initial acute
cholinergic crisis and an intermediate phase of respiratory paralysis
(24 to 96 hours), followed at 1 to 3 weeks by neuropathy. Physical
symptoms and signs include bronchospasm, nausea and vomiting, blurred
vision, diaphoresis, confusion, anxiety, respiratory paralysis, and
- Dietary history: the use of extreme diets (such as vegan diets),
eating disorders, or malnutrition related to alcoholism, drug
dependence, or deprivation increases risk of vitamin deficiencies. Deficiencies of vitamin B12, folate, thiamine, and niacin can all cause psychosis. A malabsorption syndrome may produce changes in bowel habit.
- Recent surgery: hypoxia should be considered if an acute psychosis occurs during the postoperative period.
- Family history may reveal a genetic-based neurological, metabolic,
or autoimmune disorder in a first-degree relative. Wilson’s disease is
the most common inherited cause of psychosis. A history of a primary
psychotic disorder in a first-degree relative may also be present.
- Travel history: if infectious encephalitis is suspected as the
cause, a travel history is important to assess the risk of exposure to
infectious causes, such as parasites (rare in the US).
- Click here to view full article
SEE DORIS RAPP'S VIDEO ON THE DANGEROUS PRACTICE OF DRUGGING CHILDREN BEFORE SCREENING FOR ALLERGIES AND TOXIC EXPOSURES