Management of acute psychoses

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When the psychosis is believed to be triggered by the perceived stress of the treatment environment, it is advisable to transfer the patient as soon as possible to a less intimidating environment, for example from an intensive care unit to a general ward or from a general ward to the patient's home, if adequate care is available there. Rapid tranquillisation may be needed if there is aggressive or disruptive behaviour. Chlorpromazine or haloperidol may be given in doses similar to those used in acute mania. If very rapid control of symptoms is required, diazepam can be given intravenously in a dose of 5-10 mg as Diazemuls. Intravenous therapy ensures near immediate delivery of the drug to its site of action and effectively avoids the danger of inadvertent accumulation of slowly absorbed intramuscular doses. Note also that intravenous doses can be repeated after only 5-10 minutes if no effect is observed.51 A recent review of rapid tranquillisation has recommended that the mainstay of pharmacological treatment should be parenteral benzodiazepines used with due care.52 In an emergency, and if the patient is considered to lack capacity to give or withhold consent to treatment, medication can be administered under common law if it is thought to be in the person's best interest, for example to reduce the risk of violence or self-harm until a Mental Health Act assessment is arranged.53,54 A patient's capacity to consent may be temporarily affected by many factors, including confusion, panic, shock, pain, fatigue, or drugs.

These antipsychotic drugs are well recognised as having unpleasant extrapyramidal side effects. The most dangerous of these, but fortunately the least frequent, is the neuroleptic malignant syndrome in which extrapyramidal rigidity and akathisia develop abruptly or within a few days.55 Pyrexia is always present, together with autonomic disturbances including profuse sweating, increased salivation, hyperventilation, tachycardia, and labile blood pressure. Laboratory investigations show a leucocytosis and a raised creatinine kinase. The incidence of the condition is not known but is probably well under 1% of cases treated with antipsychotics if strict diagnostic criteria are applied. Antipsychotics should be stopped immediately once the condition is diagnosed. Rapid improvement is seen if a dopamine agonist such as bromocriptine is administered, and the mortality rate has been considerably reduced by this treatment. The newer "atypical" antipsychotics should be used in the treatment of psychotic disorders associated with organic brain lesions. If antipsychotic drugs are ineffective or contraindicated, lorazepam 2-4 mg can be given orally or intramuscularly every two hours, with a maximum daily dose of 10 mg.

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