It could present with positive psychotic symptoms (exaggerations or distortions of normal thoughts, emotions, and behaviour) such as formal thought disorder, hallucinations, delusions, disorganised thinking (typically manifesting as disorganized speech), grossly abnormal behaviour, catatonic behaviour and experiences of control or passivity. It can also present with negative symptoms (functioning below normal behaviour), including alogia, anhedonia, impoverished speech, blunted or flat affect, avolition, apathy, perplexity, and social withdrawal. It is usually of sudden onset, mostly lasting from a few days to one month (DSM V) and maximally not exceeding three months (ICD 11).

The commonest causes of acute psychosis include Mental disorders such as acute and transient psychotic disorder, bipolar affective disorder (especially manic episode with psychosis), schizophrenia (especially the first episode), delusional disorder, severe depressive episode with psychosis, post-traumatic stress disorder, and attention deficit hyperactivity disorder, etc.

Other differential diagnoses include: Substance use disorders (intoxication, withdrawal etc), Neurological disorders (Temporal lobe Epilepsy, cerebrovascular disease, Encephalitis, Meningoencephalitis etc), Physical causes can be acute infections (UTI, Enteric fever, Meningitis), Chronic conditions (HIV, SLE, Huntington’s disease), Drugs/Toxins (steroids, narcotics, heavy metals, anaesthetics such as ketamine), Metabolic (fluid imbalance, electrolyte derangement), Endocrinopathies (Thyrotoxicosis, Hyperparathyroidism,), Trauma (traumatic brain injury, post-operative). An underlying predisposition can be precipitated by acute illness, pain, dyselectrolaemia, hypoxemia, anaemia, frequent procedures, sensory deprivation, sensory overstimulation, and adverse life events such as loss, acute stressful life events, or psychosocial trauma.

These can include urine drug toxicology, full blood count (can exclude anaemia, an elevated white cell count may suggest an infection), serum electrolytes (identifies precipitants such as electrolyte derangement, renal impairment, and dehydration). Other tests may include urinalysis, HIV testing, Neuroimaging, Electroencephalography, and Liver function tests, among others (where indicated).

Management of acute psychosis is best individualised, multistage, and by specialist multidisciplinary early intervention teams that render biopsychosocial interventions. The principles of care include:

1. Environmental manipulation: Identifying harmful components of the environment and addressing the environmental factors precipitating and perpetuating psychotic symptoms.
2. Standard Operating Procedure for Emergency Armamentarium

• Crisis intervention and De-escalation techniques (Verbal) in case of aggression, agitation or violence
• Use of chemical (pharmacologic) restraints
• Physical (mechanical) restraints: they are the emergency intervention of last resort to manage aggressive or agitated patients in the emergency department. It can be used to protect the safety of the patient and those around them when the least restrictive measures fail and a patent poses immediate danger to themselves and others. Restraint requires a time-limited medical order written by a physician or licensed practitioner.

Common examples of chemical restraints are;

• Use of Parenteral Diazepam and Haloperidol
• Intravenous Diazepam dose should be titrated till patient starts yearning and usually in the range of 20-30mg statum dose, not more than three doses in 24 hours.
• Intramuscular Haloperidol should be administered 5-10mg statum dose and can be repeated 30 minutes to an hour if agitation persists, not more than 15mg in 24 hours.
• High doses of haloperidol can cause dystonic reactions, use Biperiden (I.M 5mg stat) to treat acute reactions.
• Intramuscular chlorpromazine and paraldehyde: The use of I.M Chlorpromazine is not recommended except otherwise considered, due to its possible hypotensive effect and tendency to worsen physical health conditions.
• Use of parenteral (intramuscular) or oral haloperidol and promethazine (5/25mg or 10/50mg) for psychosis-induced aggression. The combination was shown to be more effective and safer with less risk of acute dystonia and excessive sedation
• Use of atypical antipsychotics e.g. olanzapine, ziprazidone etc
• Generally, a low-dose, well-tolerated second-generation antipsychotic can improve symptoms, increase medication adherence, and reduce relapses in the future.

1. Psychosocial interventions: With more sophisticated treatments, cognitive behaviour therapy and other interventions can detect specific presentations, thus improving recovery and reducing relapse from about 40% using antipsychotics alone to 18-20% adopting the biopsychosocial modality.
2. Treating the underlying cause: appropriate and best using consultation-liaison model, involving an early intervention team and other specialists at the beginning of treatment, not at the end.
3. Monitoring and Follow-up: Monitoring for occult physical and other mental problems is crucial because comorbidities are frequent and become more prevalent as people age. In the first 72 hours, it is essential to regularly check the situation to determine whether the mental state has improved, how well their medication works, how much supervision is necessary, and whether they can do their legal obligations. This is also a good time to gather information from relatives and set up any required investigations, such as routine checks and physical examinations that might not have been feasible initially. Documentation of the frequency of nursing observations (vital signs) and daily monitoring of fluid balance in acutely ill patients is an essential component of the management.

Psychosis is one of the common presentations in the emergency unit. It could be primary (functional psychosis) or secondary from an identifiable cause that should be unraveled. Every effort should be made to include the standard components of sound medical practice in treating acute psychosis. Early intervention in critical times is invaluable as it can fasten response, enhance remission, reduce hospitalization period, improve social functioning, and restore into the community to function optimally.