Intensive care and restrictions
To relieve severe conditions in an intensive care unit, inhalation anesthesia combined with muscle relaxants is used. Controlled brain hypothermia and hemoperfusion can also be effective as additional methods. If psychosis is associated with a tumor, emergency decompressive surgery is indicated.
It is strictly contraindicated to use medications that can provoke seizure activity. This list includes ketamine, sulfocamphocaine, bemegride, nikethamide, camphor, and neostigmine methylsulfate.
Febrile schizophrenia
This is a critical condition historically known as "fatal catatonia" (K. Stauder, 1934). Before the advent of antipsychotics, mortality reached 100%, but today adequate treatment saves the lives of the majority of patients. The pathology occurs predominantly in young patients (under 30 years of age) with a periodic or attack-like (schub-like) course of the disease and often becomes the very first episode.
The disease progresses very rapidly. Against the background of acute sensory delusions or oneiric catatonia, fever joins early on.
Symptoms at the peak of the attack:
- Body temperature rises above 40 °C.
- Severe dehydration develops: facial features become sharp, mucous membranes dry out, and the patient sweats profusely.
- The cardiovascular system suffers from severe tachycardia (disproportionate even to mild subfebrile temperature) and a drop in blood pressure.
- Hemorrhagic syndrome develops with a tendency to easy bruising and bleeding.
- Against the background of decreased blood pressure, consciousness becomes deeply clouded, up to the development of amentia.
The main cause of death in such patients is acute vascular failure.
Principles of treatment
At later stages, the basis is nonspecific intensive care aimed at maintaining homeostasis:
- Infusion therapy: dextrans (high- and low-molecular-weight), polyionic mixtures, sodium bicarbonate, and dextrose with added insulin.
- Combating cerebral edema: diuretics, glucocorticoids, oxygen inhalation.
- Correction of hypotension: vasopressors (norepinephrine, phenylephrine).
- Fever reduction: physical cooling, droperidol, metamizole sodium.
- Metabolic support: ascorbic acid, nootropics.
- Relief of agitation: lorazepam or diazepam in high doses.
Electroconvulsive therapy (ECT) demonstrates high efficacy, but is used only in the first 3 days of the attack, strictly before deep impairment of consciousness develops. Antipsychotics (particularly chlorpromazine) are prescribed with extreme caution, and butyrophenone derivatives are completely excluded from treatment regimens.
Differential diagnosis
The presence of hyperthermia in a patient with psychosis requires the immediate exclusion of other dangerous syndromes.
| Syndrome | Key differences and features |
|---|---|
| Neuroleptic malignant syndrome | Muscle rigidity, profuse sweating, and fecal and urinary incontinence are always present. Laboratory tests show: elevated CK, transaminases, myoglobinuria. |
| Serotonin syndrome | Moist skin, tremor, sometimes myoclonus and hypomania. No specific changes in laboratory tests. |
| Malignant hyperthermia | Dry skin, often cyanosis. Accompanied by DIC syndrome, acidosis, hyperkalemia. |
| Anticholinergic delirium | Dilated pupils, dry skin, delirium, constipation, urinary retention, frequent memory impairment. |
| Agranulocytosis | Presence of inflammatory processes (tonsillitis, stomatitis, pneumonia, acne). Blood tests reveal leukopenia and elevated ESR. |
Briefly: answers to topical questions
What blood changes and clinical manifestations are characteristic of agranulocytosis in the differential diagnosis of psychoses?
Agranulocytosis is characterized by a sharp decrease in the number of neutrophil leukocytes in the blood, leukopenia, and an elevated erythrocyte sedimentation rate (ESR).
Clinical manifestations include:
- Hyperthermia — usually accompanied by elevated temperature.
- Inflammatory processes — severe tonsillitis, stomatitis, pneumonia.
- Skin lesions — pustular and acneiform rashes, staphylococcal lesions.
- Mental disorders — confusion and hallucinations sometimes occur.
- Cardiovascular system — tachycardia and arterial hypotension are sometimes noted.
- Gastrointestinal disorders — diarrhea sometimes occurs.
What cardiovascular complications occur in febrile schizophrenia?
In febrile schizophrenia, marked disproportionate tachycardia and blood pressure disorders are noted: the clinical picture describes a drop in blood pressure, and the differential table lists arterial hypertension and tachycardia. Hemorrhagic syndrome is also possible, manifested by easy bruising and bleeding. The cause of death is acute vascular failure.
To memorize the triad of physical disturbances in febrile schizophrenia, use the mnemonic "TDC": Temperature (above 40), Dehydration (dry mucous membranes, sweating), Circulation (tachycardia, drop in BP, bruising).
Class and exam questions
In general, antipsychotics are used with great caution due to the difficulty of differential diagnosis with neuroleptic malignant syndrome (NMS). The use of butyrophenones in this clinical situation is considered unacceptable.
In general, antipsychotics are used with great caution due to the difficulty of differential diagnosis with neuroleptic malignant syndrome (NMS). The use of butyrophenones in this clinical situation is considered unacceptable.
What is the prognosis after arresting a febrile schizophrenia episode?
As a rule, after recovering from acute psychosis, the patient develops a good-quality remission without pronounced personality changes. However, it is worth remembering that the second and third episodes may also be accompanied by the development of hyperthermia.
When can ECT be performed in a patient with acute psychosis?
Electroconvulsive therapy provides an excellent effect, but it is permitted to be used exclusively at the very beginning of the attack (in the first 3 days) and strictly before the formation of deep disturbances of consciousness (amentia).
What else to study on this topic
- Clinical picture and phases of development of oneiric catatonia.
- Specifics of using inhalation anesthesia and muscle relaxants in psychiatric practice.
- Mechanisms of development of acute vascular failure in hypertoxic psychoses.
- Pathogenesis of neuroleptic malignant syndrome and the role of creatine phosphokinase (CK).
Master the entire topic in the "Psychiatry" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Acute Psychosis" and 499 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 7 video lessons on the subject
Other topics in the section "Chapter 28. Psychiatric Emergencies"
Entire section "Chapter 28. Psychiatric Emergencies"Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.