Psychotic behavior reflects an inability or unwillingness to recognize and acknowledge reality and to relate with others. It may begin suddenly or insidiously, progressing from vague complaints of fatigue, insomnia, or headaches to withdrawal, social isolation, and preoccupation with certain issues, resulting in gross impairment in functioning.
Various behaviors together or separately can constitute psychotic behavior. These include delusions, illusions, hallucinations, bizarre language, and perseveration. Delusions are persistent beliefs that have no basis in reality or in the patient’s knowledge or experience such as delusions of grandeur. Illusions are misinterpretations of external sensory stimuli such as a mirage in the desert. In contrast, hallucinations are sensory perceptions that don’t result from external stimuli. Bizarre language reflects a communication disruption. It can range from echolalia (purposeless repetition of a word or phrase) and clang association (repetition of words or phrases that sound similar) to neologisms (creation and use of words whose meaning only the patient knows). Perseveration, a persistent verbal or motor response, may indicate organic brain disease. Motor changes include inactivity, excessive activity, and repetitive movements.
Because the patient’s behavior can
make it difficult — or potentially dangerous — to obtain pertinent information, conduct the interview in a calm, safe, and well-lit room. Provide enough personal space to avoid threatening or agitating the patient. Ask him to describe his problem and circumstances that may have precipitated it. Obtain a drug history, noting especially the use of an antipsychotic, and explore his use of alcohol and other drugs, such as cocaine, indicating duration of use and amount. Ask about recent illnesses or accidents.
As the patient talks, watch for cognitive, linguistic, or perceptual abnormalities such as delusions. Do thoughts and actions seem to match? Look for unusual gestures, posture, gait, tone of voice, and mannerisms. Does the patient appear to be responding to stimuli? For example, is he looking around the room?
Interview the patient’s family. Which family members does he seem closest to? How does the family describe the patient’s relationships, communication patterns, and role? Has a family member ever been hospitalized for psychiatric or emotional illness? Ask about the patient’s compliance with his drug regimen.
Finally, evaluate the patient’s environment, educational and employment history, and socioeconomic status. Are community services available? How does the patient spend his leisure time? Does he have friends? Has he ever had a close emotional relationship?
Various organic disorders, such as alcohol withdrawal syndrome, cocaine or amphetamine intoxication, cerebral hypoxia, and nutritional disorders, can produce psychotic behavior. Endocrine disorders, such as adrenal dysfunction, and severe infections, such as encephalitis, can also cause psychotic behavior. Neurologic causes include Alzheimer’s disease and other dementias.
Psychotic behavior usually occurs with bipolar disorder, personality disorder, schizophrenia, and some pervasive developmental disorders.
Certain drugs can cause psychotic behavior. (See Psychotic behavior: An adverse drug effect.) However, almost any drug can provoke psychotic behavior as a rare, severe adverse or idiosyncratic reaction.
Postoperative delirium and depression may produce psychotic behavior.
Continuously evaluate the patient’s orientation to reality. Help him develop a conception of reality by calling him by his preferred name, telling him your name, describing where he is, and using clocks and calendars. (See Controlling psychotic behavior.)
Encourage the patient to become involved in structured activities. However, if he’s nonverbal or incoherent, make sure to spend time with him. For example, sit or walk with him or talk about the day, the season, the weather, or other concrete topics. Avoid making time commitments that you can’t keep: This will only upset the patient and cause him to withdraw more.
Refer the patient for psychiatric evaluation. Administer an antipsychotic or other drugs, as needed, and prepare him for transfer to a mental health center, if necessary.
Don’t overlook the patient’s physiologic needs. Check his eating habits to avoid dehydration and malnutrition, and monitor his elimination patterns, especially if he’s receiving an antipsychotic, which can cause constipation.
In a child, psychotic behavior may result from early infantile autism, symbiotic infantile psychosis, or childhood schizophrenia — any of which can retard language development, abstract thinking, and socialization. An adolescent patient who exhibits psychotic behavior may have a history of several days’drug use or lack of sleep or food, which must be evaluated and corrected before therapy can begin.
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
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Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1 
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