Unit 4: Psychotic disorders,

Organic brain syndrome and

Mood disorders

• Psychotic Disorder

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 Introduction to Psychosis
Psychosis
• A syndrome involving the loss of contact with reality

• Hearing voices or seeing things that are not there

• False beliefs / suspicions

• The person may not be aware of the psychosis

Acute psychosis
• The symptoms started within last 3 months or there is a
worsening of symptoms
• It can be a first episode Muhammed
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or a relapse 2
 Natural history of psychosis
• First onset typically between age 15 and 25 years.
• There are 3 possible clinical courses
– the person recovers completely or partially with
some symptoms
– the person recovers but has a future episode (relapse)
– symptoms continue for 3 months or more (chronic
psychosis)

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 Facts about psychosis
• Psychosis occurs frequently- one person among 100 to 200
• dramatic impact on individuals, families and society.
– Loss of relationships and income opportunities
– Human rights violations (discrimination, abuse)
– Burden on carers (time, money, stigma)
• Psychosis can be managed outside hospitals
– e.g., at primary health care clinics
• Care can be offered in non-specialized health care
– Medical treatment is simple and effective
– More accessible than specialist care
– Less stigmatized than care in mental hospitals

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 Key feature of psychotic disorders
 Delusion
 Halucination
 Disorganized Thinking (Speech): derailment/loose associations,
tangentiality, incoherence/ "word salad“, etc.
 Grossly Disorganized/Abnormal motor Behavior
including Catatonia: ranging from childlike "silliness" to
unpredictable agitation.
 Catatonic behavior: negativism; maintaining a rigid, bizarre
posture; mutism & stupor; purposeless & excessive motor activity
without obvious cause {catatonic excitement}; staring, grimacing,
mutism, and the echoing of speech
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 Key feature of psychotic disorders…
 Negative Symptoms :
• Highly associated with schizophrenia but less prominent in other
psychotic disorders.
• The 1st two negative symptoms are prominent in schizophrenia:-
1, Diminished emotional expression: reductions in the expression
of emotions in the face, eye contact, intonation of speech
(prosody), and movements of the hand, head, and face that
normally give an emotional emphasis to speech.
2, Avolition : lack of motivation in self-initiated purposeful
activities. sitting for long periods of time and show little interest
in participating in work or social activities.
3, Alogia diminished speech
4, Anhedonia lack of pleasure for positive stimuli
5,01/18/2026
Asociality the apparent lack of interest in social interactions 6
 Psychotic Disorder
• Includes:
 Schizophrenia
 Schizoaffective disorder
 schizophreniform
 brief psychotic disorder,
 delusional disorder, etc

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 Schizophrenia
Historical Overview
 Emil Kraepelin introduced the concept of:

 Dementia Praecox:
 Often have delusions and hallucinations

 Long term deteriorating course

 Eugen Bleuler coined the term schizophrenia(the split b/n

the individual and reality)

 Identified primary symptoms:

 Loosening of Associations; Affective blunting; Autism;
Ambivalence
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 Historical Overview...
Kurt Schneider - first rank symptoms:
• Audible thoughts

• Voices arguing or discussing

• Voices commenting

• Thought withdrawal or insertion

• Thought broadcasting

• Delusional perception

• Experiences involving volition, made affects & made

impulses
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 Epidemiology
Incidence and prevalence
– The life time prevalence is ~1%
– Schizophrenia is found in all societies and geographical areas
and prevalence ratios are roughly equal.
 Male : Female= 1:1
 Peak age of onset – 21 in men and 27 in women
 High mortality rates: accidents, undiagnosed medical illnesses
 5-6% commit suicide (20% attempt)
 High rate of Substance use: cigarette, alcohol, cannabis
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 Schizophrenia - Etiology
• Bio psycho social (stress – diathesis)
1. Genetic factors:
– Monozygotic twins – 47%
– Dizygotic twins – 12%
2. Neuroimaging and Neuropathology
– Decreased size in the areas of limbic system
– Enlarged third and lateral ventricles
3) Neurodevelopment theories
– Abnormal neuronal migration during the second trimester
fetal development.
– Abnormal neuronal functioning may lead to the emergence of
symptoms during adolescence.
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 = healthy
neuron
= defective
neuron

good neuronal selection bad neuronal selection

4-6 Stahl S M, Essential
01/18/2026 Psychopharmacology 12(2000)
 good migration bad migration

4-7 Stahl S M, Essential

01/18/2026 Psychopharmacology 13(2000)
 CORRECT WIRING

4-8 Stahl S M, Essential

01/18/2026 Psychopharmacology 14(2000)
 WRONG WIRING

4-9 Stahl S M, Essential

01/18/2026 Psychopharmacology 15(2000)
 Schizophrenia – Etiology..

Dopamine Hypothesis
– Schizophrenic symptoms may result from
• Increase limbic dopamine activity positive symptoms
• Decreased frontal dopamine activity negative
symptoms
Amphetamine like substances cause psychotic symptoms
Expressed emotions:
– Hostility, critical comments, emotional over-
involvement
– Importance of the family atmosphere in the course of
schizophrenia
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 Positive symptoms

• Hallucinations
• Delusions
• Thought form
disorder

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 Negative Symptoms

• Avolition - under activity, lack of initiative, poor self care

• Attentional impairment
• Alogia - poverty of speech & speech content
• Affective flattening or blunting
• Anhedonia - loss of pleasure
• Social withdrawal

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 Diagnostic Criteria for Schizophrenia
DSM-V Diagnostic Criteria for schizophrenia
A. Two (or more) of the following, each present for a significant
portion of time during a 1 -month period (or less if successfully
treated)
• At least one of these must be (1 ), (2), or (3):
• 1. Delusions.
• 2. Hallucinations.
• 3. Disorganized speech (e.g., frequent derailment or incoherence).
• 4. Grossly disorganized or catatonic behavior.
• 5. Negative symptoms ([Link] emotional expression or
Avolition, Alogia, Anhedonia, Asociality).
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Diagnostic Criteria for Schizophrenia…
B. Social/occupational dysfunction
C. Duration: Continuous signs of the disturbance persist for at
least 6 months
D. Schizoaffective and Mood Disorder Exclusion
E. Substance /Another Medical Condition Exclusion
F. If there is a history of autism spectrum disorder or a
communication disorder of child­hood onset, the Dx of
schizophrenia is made only if prominent delusions or
hallucinations
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 Clinical features
• Schizophrenia is a phenomenological diagnosis
based on observation and description of the
patient.
• General rules:
1. A patient’s symptoms change with time
2. Patient’s educational level, intellectual ability &
cultural membership must be taken into account.

Affect:
Blunted, Flat, Labile, Silly, Inappropriate
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 Clinical features…
Sense of self impaired
– Loss of ego boundaries
– Gender confusion
– Inability to distinguish internal from external reality

Volition altered

Inadequate drive or motivation

Interpersonal Functioning impaired

– Social withdrawal
– Aggressiveness, impulsiveness, violence
–
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 Clinical features…
psychomotor /behavior

Agitation, withdrawal, posturing, etc.

Cognition impaired

e.g. Inattention, impaired information processing

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 Treatment Schizophrenia
Treatment of Acute Psychosis
• require immediate attention.
• focuses on alleviating the most severe psychotic
symptoms.
• Antipsychotics and benzodiazepines can result in relatively
rapid calming of patients.
• With highly agitated patients, IM administration of
antipsychotics produces a more rapid effect.
• A single IM injection of haloperidol (Haldol), will often result
in calming without an excess of sedation.

• Haloperidol 5mg
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Diazepam 5-10mg IM 24
 Antipsychotic Agents & Schizophrenia
• Antipsychotic Agents:
– A chemically diverse group of compounds employed
to treat a broad spectrum of psychotic disorders:-

• Schizophrenia,
• delusional disorders,
• acute mania,
• depressive psychoses,
• drug induced psychoses.

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Antipsychotic Agents & Schizophrenia…
Antipsychotic Agents: Two major groups
 Conventional Antipsychotics, first-generation, typical,
traditional
Block receptors for dopamine D2 in the CNS

 Atypical Antipsychotics, second-generation, or serotonin

dopamine antagonists (SDAs)
Only produce moderate blockage of receptors for dopamine
D2 and much stronger blockade of receptors for serotonin26
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 Antipsychotic Agents…
1st generation(D2-Affinity) e.g.

• Chlorpromazine (Largactile®) 100-300mg po/day

• Thioridazine (Mellaril®) 100-300mg po/day

• Trifluoperazine (Stelazine®) 5-15mg po/day
• Haloperidol (Haldol®) 5-10mg po/day
• Fluphenazine decanoate 12.5mg-25 mg IM/month

Newer drugs (5HT2-Affinity) e.g.

• Olanzapine 5-10 mg po/day

• Risperidone 2-6 mg po/day

• 01/18/2026
Clozapine 25-300 mg po/day
27
 Side Effects of Typical Antipsychotics
Extra pyramidal side effect(serious movement disorder)
• Parkinsonism: muscle stiffness (lead pipe rigidity),
cogwheel rigidity, shuffling gait, stooped posture, and
drooling. Tremor of hands, tongue, lips and perioral
muscles
• Akathisia- subjective feelings of restlessness, objective
signs of restlessness, or both
• Dystonia-spasms of muscle groups of neck, back, eyes
• Tardive dykinesia (may be irreversible )-involuntary
movements (tongue protrusion, blinking, grimacing,
foot tapping)

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 Side effects…
• Neuroleptic Malignant syndrome is potentially fatal(NMS): fever,
tachycardia, sweating, muscle rigidity, confusion, tremor, elevated
creatine phosphokinase, renal failure
Other side effects
• Seizures(Decreased seizure threshold)

• Anticholinergic side effects- constipation, dry mouth, blurred

vision, urinary retention

• Orthostatic hypotension due to α1 adrenergic blockage

• Sedation

Sexual dysfunction
• 01/18/2026 29
01/18/2026 30
 Indications for hospitalization
1. Psychotic symptoms prevent the patient from
caring for his basic needs.

2. Suicidal ideation, often secondary to psychosis

3. Patients who are a danger to themselves or others

4. Patients with command hallucinations to harm self

or others should be evaluated for hospitalization,
especially with a history of acting on hallucinations.
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 Poor Prognosis
Good Prognosis • Young onset
• Late onset • No precipitating factors
• Obvious precipitating factors • Insidious onset
• Acute onset • Poor premorbid social and
• Good premorbid social, work histories)
sexual, and work histories • Single, divorced, or widowed
• Mood disorder symptoms • Family history of schizophrenia
(especially depressive • Poor support systems
disorders) • Negative symptoms
• Married • Neurological signs & symptoms
• Family history of mood • History of perinatal trauma
disorders • No remissions in 3 years
• Good support systems • Many relapses
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Positive symptoms • History of assaultiveness 32
 Schizophrenia - Prognosis

• 20-30% are able to lead some what

normal lives
• 20-30% continue experience moderate
symptoms
• 40-60% remain significantly impaired
for their entire lives.
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 Schizoaffective disorders
Definition
schizoaffective disorder has features of both
schizophrenia and affective disorders (mood
disorders).
 The diagnosis is based on the assessment of an
uninterrupted period of illness during which at
some time, either there is a Major Depressive
Episode, a Manic Episode, or a Mixed Episode
concurrent with symptoms that meet Criterion A
for schizophrenia
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 Cont……….
Epidemiology
• The lifetime prevalence is <1 % (0.3%)
• higher in females than in males, mainly
due to an increased incidence of the
depressive type among females.
• The depressive type of schizoaffective
disorder may be more common in older
persons than in younger persons,
• The bipolar type may be more common
in young adults than in older adults.
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DSM-V Diagnostic Criteria for Schizoaffective
Disorder
A. An uninterrupted period of illness during which, at
some time, there is either a major depressive episode
or a manic episode, concurrent with symptoms that
meet Criterion A for schizophrenia.

Note: The major depressive episode must include

Criterion A1: depressed mood.
B. During the same period of illness, there have been
delusions or hallucinations for at least 2 weeks in the
absence of prominent mood symptoms.

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 Cont……..
C .Symptoms that meet criteria for a mood episode are
present for a substantial portion of the total duration
of the active and residual periods of the illness.
substantial portion of the total duration at least 15-
20%.it can’t be less than 15%
D. Role out substance (e.g., a drug of abuse, a
medication) or a general medical condition.
• Specify type:
Bipolar type: if the disturbance includes a manic
episode (or a manic and major depressive episodes)
Depressive type: if the disturbance only includes
major depressive episodes
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 Treatment
• Antipsychotic +Mood stabilizers for bipolar type
• Antipsychotic + Antidepressant for depressive type

• ECT
• psychotherapy

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 Schizophreniform disorder
Definition
• DSM-V describes schizophreniform disorder as similar
to schizophrenia, except that its symptoms last at least 1
month but less than 6 months.
• Patients with schizophreniform disorder return to their
baseline level of functioning once the disorder has
resolved
• acute psychotic disorder that has
• a rapid onset and lacks a long prodromal phase
• they are unlikely to report a progressive decline in
social and occupational functioning.
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 Cont………..
• There would be emotional turmoil and confusion,
which may indicate a good prognosis
• By definition, pts with schizophreniform disorder
return to their baseline state within 6 months
• In some instances, the illness is episodic, with more
than one episode occurring after long periods of
full remission.
• If the combined duration of symptomatology
exceeds 6 months, however, then schizophrenia
should be considered.

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 Cont……..
Specify if:
 Without good prognostic features
 With good prognostic features: as evidenced by
two (or more) of the following:

 Onset of psychosis within a month of change in behavior

 Confusion during peak of illness
 Good functioning before illness
 No negative symptoms (absence of blunted or flat
affect)

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 Treatment
• Hospitalization is often necessary for effective
assessment, treatment and supervision of a pt's
behavior.
• Can usually be treated by a 3- to 6-month course of
antipsychotic drugs (e.g., risperidone)
• Respond to antipsychotic treatment much more rapidly
than schizophrenia
• Electroconvulsive therapy may be indicated for some
patients, especially those with marked catatonic or
depressed features
• Psychotherapy to help pts integrate the psychotic
experience into their understanding of their own minds
and lives.
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 Brief Psychotic Disorder
 a psychotic condition that involves the sudden
onset of psychotic symptoms, which lasts 1 day
or more but less than 1 month.
 Remission is full, and the individual returns to
the premorbid level of functioning

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 Epidemiology
• The exact incidence and prevalence is unknown
• More often among younger patients (20s and 30s)
• May be seen most frequently in pts from low
socioeconomic classes and in those who have
experienced disasters or major cultural changes (e.g.,
immigrants).

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 Comorbidity

• Often seen in pts with personality disorders

(most commonly, histrionic, narcissistic,

paranoid, schizotypal, and borderline

personality disorders).

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 Diagnosis DSM_V criteria
A. Presence of one (or more) of the following symptoms. At least one must

be (1), (2), or (3):

• 1. Delusions
• 2. Hallucinations

• 3. Disorganized speech (e.g., frequent derailment or incoherence)

• 4. Grossly disorganized or catatonic behavior.

B. Duration is at least 1 day but less than 1 month

C. Role out MDD or BPD with psychotic features or another psychotic

disorder(schizophrenia or catatonia), and physiological effects of a

substance or another medical condition.

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• Specify if:

• With marked stressor(s): If symptoms occur in response to

events markedly stressful to almost anyone in similar
circumstances in the individual’s culture.

• Without marked stressor(s): If symptoms do not occur in

response to events markedly stressful to almost anyone

• With postpartum onset: If onset is during within 4 weeks

postpartum.

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 Differential Diagnosis
• schizophreniform disorder, schizoaffective disorder,
schizophrenia, mood disorders with psychotic features,
• delusional disorder,
• factitious disorder and malingering,
• psychotic disorder due to GMD and substance-induced
psychotic disorder.
• Pts with epilepsy or delirium.
• dissociative identity disorder
• borderline and schizotypal personality disorders.
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 Treatment
• Hospitalization

• brief hospitalization for both evaluation and protection.

• seclusion, physical restraints, or one-to-one monitoring

of the pt may be necessary
• Pharmacotherapy

• antipsychotic drugs and/or

• the benzodiazepines
Long-term use of medication is often not necessary and
should be avoided
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 Delusional Disorder

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 Delusional Disorder
• Delusional disorder refers to a group of disorders, the chief
feature of which is the presence of nonbizarre delusion
• Nonbizarre delusions typically involve situations or
circumstances that can occur in real life (e.g., being
followed, infected, or deceived by a lover) and are
believable.

• People suffering from this illness generally do not regard

themselves as mentally ill and actively oppose psychiatric
referral.
• Because they may experience little impairment, they
generally remain outside hospital settings, appearing
reclusive, odd, rather than ill.
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 Cont…………..
• They are more likely to have contacts with
professionals such as lawyers and other medical
specialists for health concerns.
In general, the individual’s delusions are well
systematized and have been logically developed.

If the person experiences auditory or visual

hallucinations, they are not prominent except for
tactile or olfactory hallucinations where they are
tied in to the delusion
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 Cont…………………..
(e.g., a person who believes that he emits a foul
odor might experience an olfactory Hallucination
of that odor).
The person’s behavioral and emotional responses
to the delusions appear to be appropriate.

Usually, the person’s functioning and personality

are well preserved and show minimal
deterioration if at all.

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DSM-V Diagnostic Criteria for delusional
disorder
A. The presence of one (or more) delusions with a

duration of 1 month or longer

B. Criterion A for schizophrenia has never been met.

C. Apart from the impact of the delusion(s) or its

ramifications, functioning is not markedly

impaired, and behavior is not obviously bizarre or

odd.
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 DSM-V Diagnostic Criteria…
Subtypes:

Erotomanic type: delusions that another person, usually of

higher status, is in love with the individual.

Grandiose type: delusions of inflated worth, power, knowledge,

identity, or special relationship to a deity or famous person

Jealous type: delusions that the individual's sexual partner is

unfaithful

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 DSM-V Diagnostic Criteria…
Persecutory type: delusions that the person (or someone to

whom the person is close) is being malevolently treated in

some way

Somatic type: delusions that the person has some physical defect

or general medical condition

Mixed type: delusions characteristic of more than one of the

above types but no one theme predominates

Unspecified type: the dominant delusional belief cannot be clearly

determined or is not described in the specific types

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 Treatment
• Delusional disorder was generally regarded as resistant to

treatment
• Pharmacotherapy
• In an emergency, severely agitated patients should be given an
antipsychotic drug IM.
• start with low doses of haloperidol or risperidone

Psychotherapy

• Individual therapy

• insight-oriented, supportive, cognitive, and behavioral therapies

are often effective.

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 Post partum Psychosis
(puerperal psychosis)

• occurs in women who have

recently delivered a baby;
• the syndrome is most often
characterized by the mother's
depression, delusions, and
thoughts of harming either her
infant or herself
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 Post partum Psychosis…
• The symptoms can often begin within days of the delivery,

• the mean time of onset is within 2 to 3 wks and almost always

within 8 weeks of delivery.

• patients begin to complain of fatigue, insomnia, and restlessness,

and they may have episodes of tearfulness and emotional lability.

• Later, suspiciousness, confusion, incoherence, irrational statements,

and obsessive concerns about the baby's health and welfare

• Delusional material may involve the idea that the baby is dead or
defective.
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 Post partum Psychosis…
• Pts may deny the birth and express thoughts of
being unmarried, virginal, persecuted, influenced,
or bad.
• Hallucinations with similar content may involve
voices telling the patient to kill the baby or
herself.
• Complaints regarding the inability to move, stand,
or walk are also common.
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 Post partum Psychosis…
• 10% of births develop PPP

• Very Dangerous

• Mother must always be supervised

• – Untreated 4% infanticide/50% have no Hx of mental illness

Treatment (think bipolar disorder treatment)

-Anti-depressant

– ECT

– Lithium or other mood stabilizer

–01/18/2026
But be aware of infant and breast-feeding 61
 Organic brain syndrome
Delirium
Dementia
Amnestic disorders

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 Dementia
 Multiple Cognitive Deficits:
 Memory dysfunction

 At least one additional cognitive deficit

 aphasia (language disturbance)
 apraxia (impaired ability to carry out motor activities despite
intact motor function)
 agnosia (failure to recognize or identify objects despite intact
sensory function)
 disturbance in executive functioning (i.e., planning, organizing,
sequencing, abstracting)
 Cognitive Disturbances:
 Sufficiently severe to cause impairment of occupational or
social functioning and
 Must represent a decline from a previous level of functioning
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 Dementia
• It is a syndrome involving:

 deterioration in memory,
 thinking, behavior and
 the ability to perform everyday
activities such as dressing,
eating, personal hygiene and
toilet activities

• It generally affects older people,

although it is not a normal part of

ageing.
01/18/2026 64
 prevalence
• Estimated prevalence is 4.7% among people 60 years and over
• This indicates that 35.6 million people are living with dementia
• The total number of people with dementia is projected to almost
double every 20 years
• That is, to 65.7 million by 2030 and up to 115.4 million by 2050
dementia(WHO. Dementia: a public health priority, 2012).
• Much of this increase is attributable to the rising numbers of
people with dementia living in low- and middle-income
countries ( Figure 1).
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Figure 1: Increase in numbers of people with dementia, by
income
01/18/2026 group of countries 66
• In Ethiopia, the number of people suffering
from dementia was estimated to be 76,000 in
2010, rising to 281,000 by 2050 (Fekadu, A.,
et al.2007)
• Though no cure is available, much can be
done for people with dementia and their
caregivers.
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 Types of dementia based on causes
1. Alzheimer Disease (pure ~40% +
mixed~70%)
2. Vascular Disease (5-20%)
3. Drugs, Depression, Delirium
4. Ethanol (5-15%)
5. Medical / Metabolic Systems
6. Endocrine (thyroid, diabetes, B12,
Folate), Ears, Eyes.
7. Neurological (other primary
degenerations, etc.)
8. Tumor, Toxin, Trauma
9. Infection, Idiopathic, Immunologic
10. Autoimmune
01/18/2026 68
 Dementia Treatment
 Treat preventable causes
 Acetyl-Cholinesterase Inhibitor
 Vitamin E
 200-400iu po BID, increase by 200iu per dose/ week to
1000iu po BID
 Antipsychotics(haldol, risperidone) for some pts

 Caring, Empathy, Support and treat caregivers

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 Delirium (acute brain failure)
• It is a neuropsychiatric syndrome also called
acute confusional state that is common among
the medically ill and often is misdiagnosed as a
psychiatric illness which can result in delay of
appropriate medical intervention.

• mortality associated with delirium is

significantly so identifying it is crucial!
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 DSM-V Criteria
A. A disturbance in attention and awareness

B. The disturbance develops over a short period of time and

tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g. memory
deficit, disorientation, language or perception).
D. The disturbances in Criteria A and C are not better
explained by another preexisting neurocognitive disorder
and do not occur in the context of a severely reduced level
of arousal, such as coma.
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 DSM- V Criteria…

E. There is evidence from the history, physical

examination, or lab findings that the disturbance is
a direct physiological consequence of:
• another medical condition,

• substance intoxication or withdrawal or

• exposure to a toxin, or

• is due to multiple etiologies.

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 Clinical characteristics
• Develops acutely (hours to days)
• Characterized by fluctuating level of
consciousness
• Reduced ability to maintain attention
• Agitation or hypersomnolence
• Extreme emotional lability
• Cognitive deficits can occur

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 Types of delirium
Hyperactive/hyper alert
_ The patient is hyperactive, combative
(aggressive) and uncooperative.
– May appear to be responding to internal stimuli
– Frequently these patients come to our attention
because they are difficult to care for

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 Type of delirium….
Hypoactive/hypo alert
• Pt appears to be napping on and off throughout the day

• Unable to sustain attention when awakened, quickly

falling back asleep
• Misses meals, medications, appointments

• Does not ask for care or attention

• This type is easy to miss because caring for these

patients is not problematic to staff
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 Epidemiology- Delirium occurs in:
• approximately 40% of hospitalized elderly pts >65 yr
• approximately 50% of pts post-hip fracture
• approximately 30% of pts in surgical ICU
• approximately 20% of pts on general medical wards
• approximately 15% of pts on general surgical wards

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How to evaluate a pt with suspected delirium
Look at the overall time course
• Review med list including scheduled, prns doses, recent meds
discontinued or started
• Evaluate for recent medical illness and interventions
• Screen for history of substance dependence to determine risk
of withdrawal
• Review diagnostic studies including labs, imaging, vital signs
• Gather collateral information from family regarding baseline
function, personality, psychiatric history.
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 Testing
Mini mental status exam (MMSE) is not sensitive
in identifying delirium however repeated MMSEs
can reveal waxing and waning course
• Most sensitive items are serial 7’s, orientation,
recall memory
• Tests of attention include serial 7’s, spelling
WORLD backwards, months of the year
backward, counting down from 20

• Confusion Assessment Method(CAM)

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 Dementia vs Delirium
• Dementia has an insidious onset, chronic memory and
executive function disturbance, tends not to fluctuate.
• Delirium: cognitive changes develop acutely and
fluctuate.
• Dementia has intact alertness and but impoverished
speech and thinking.
• In delirium attentions, peech can be confused or
disorganized. Alertness and attention wax and wane.
01/18/2026 79
 Treatment
• First and foremost treat the underlying cause

• Environmental interventions: cues for

orientation (calendar, clock, family pictures,
windows), frequently reorient the patient, have
family or friends visit frequently making sure
they introduce themselves.
• Minimize psychoactive medications
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 Treatment-medications
• Antipsychotics decrease psychotic sx, confusion,
agitation
• Antipsychotics- IV Haloperidol is first line. Onset of
action within 5-20 minutes. After IV dose established
transition to BID or qhs oral dose and taper.
• Some data now supports use of atypical antipsychotics:
Risperdone 0.5-2mg, Quetiapine 12.5-50mg, Olanzapine
2.5-10mg.
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 Education
• Let the family know what is going on including
that delirium waxes and wanes and can last for
several weeks
• Once the patient starts to improve explain to them
what delirium is, how common it is and the usual
course.
• It is very frightening for them and may fear they
have a psychiatric illness.
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 Quiz 1

• Write the “A” diagnostic criteria of

schizophrenia? (5 marks)

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 TA L
O U T ME N
W I T H
A LT H H”
N O H E E A L T
“ H

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