Psychotic behavior reflects an inability or unwillingness to recognize or acknowledge reality and to relate appropriately to others. It may develop suddenly or gradually, progressing from vague complaints (fatigue, insomnia, headaches) to social withdrawal, preoccupation, and gross functional impairment.

Key Features

• Delusions: Persistent false beliefs (e.g., grandeur, persecution) unrelated to reality

• Illusions: Misinterpretations of real sensory stimuli (e.g., mirages)

• Hallucinations: Perceptions without external stimuli (auditory, visual, tactile)

• Bizarre language: Echolalia, clang associations, neologisms

• Perseveration: Persistent verbal/motor responses, often indicating organic brain disease

• Motor changes: Inactivity, hyperactivity, or repetitive movements

Pathophysiology

• Neurochemical Imbalance: Dysfunction in dopamine, serotonin, and glutamate pathways can disrupt perception, cognition, and behavior.

• Structural Brain Changes: Cortical or subcortical lesions, ventricular enlargement, or neuronal loss (e.g., in Alzheimer’s or schizophrenia) alter information processing.

• Neurodevelopmental Abnormalities: Early disruptions in brain development may predispose to psychosis (e.g., in childhood schizophrenia or autism).

• Organic/Metabolic Factors: Hypoxia, infections (encephalitis), nutritional deficiencies, and endocrine disorders can impair neuronal function and trigger psychotic manifestations.

History and Physical Examination

History

• Onset, duration, and progression of symptoms

• Recent illnesses, infections, trauma, or surgery

• Drug and alcohol use, including antipsychotics and stimulants

• Psychiatric or family history of psychosis or severe mental illness

Observation

• Cognitive, linguistic, and perceptual abnormalities

• Posture, gestures, gait, voice tone, and responsiveness to stimuli

• Attention to whether thoughts and actions align

Collateral Information

• Interview family for patient’s relationships, communication, and role

• Assess environment, educational/employment history, leisure activities, and social supports

Medical Causes

Emergency Interventions and Safety

• Remove potentially dangerous objects

• Maintain a calm, safe environment

• Communicate clearly, concisely, non-threateningly

• Reinforce reality gently without arguing or supporting delusions

• Stay with frightened patients; use touch only if safe

• Consider one-on-one supervision for severely bizarre or dangerous behavior

• Administer antipsychotics or other medications as ordered

Special Considerations

• Evaluate orientation to reality continually (use clocks, calendars, introductions)

• Encourage structured activities and social interaction

• Monitor physiologic needs: nutrition, hydration, elimination, especially with antipsychotic therapy

• Refer for psychiatric evaluation and mental health support as needed

Pediatric Pointers

• Causes in children: early infantile autism, symbiotic infantile psychosis, childhood schizophrenia

• Effects: delayed language, impaired abstract thinking, socialization difficulties

• Adolescent causes: acute drug use, sleep deprivation, or nutritional deficiencies

Patient Counseling

• Explain the importance of structured activities

• Review medication use and adherence

• Discuss safety measures and support systems

References

1. Lehne RA. Pharmacology for nursing care. 7th ed. St. Louis, MO: Saunders Elsevier; 2010.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary care: A collaborative practice. St. Louis, MO: Mosby Elsevier; 2008. p. 444–447.

3. Berkowitz CD. Berkowitz’s pediatrics: A primary care approach. 4th ed. USA: American Academy of Pediatrics; 2012.

4. Colyar MR. Well-child assessment for primary care providers. Philadelphia, PA: F.A. Davis; 2003.

5. Sommers MS, Brunner LS. Pocket diseases. Philadelphia, PA: F.A. Davis; 2012.