Disorganised behaviour

Disorganised behaviour is behaviour that is purposeless, bizarre, unpredictable or inappropriate to the situation, with difficulty carrying out goal directed activity, often together with disorganised speech (derailment, incoherence, tangentiality). It ranges from unusual dress and silly or childlike behaviour to agitation, wandering, self neglect and catatonic features. It is a nonspecific sign of severe mental or brain dysfunction.

The first tasks are safety and exclusion of delirium and treatable organic causes, the second is to identify primary psychosis, mood disorder, catatonia, dementia or substance related disorder, and the third is to protect the patient from self neglect, exploitation and harm.

Definitions

• Disorganised behaviour: unpredictable agitation, childlike silliness, inappropriate sexual behaviour, unusual dress, aimless activity, difficulty completing tasks of daily living, and inappropriate affect.
• Disorganised speech (formal thought disorder): loosening of associations, derailment, tangentiality, incoherence ("word salad"), neologisms, and poverty of content.
• Catatonia: abnormal motor behaviour with stupor, mutism, posturing, catalepsy, waxy flexibility, negativism, echolalia, echopraxia, stereotypy, mannerisms, grimacing, agitation and excitement.
• Self neglect: persistent failure to maintain hygiene, nutrition, health care and safe living conditions.

Classification by cause

• Primary psychosis (schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, with disorganised subtype features).
• Mood episodes (mania with disorganisation and flight of ideas, depressive stupor, mixed states).
• Catatonia (associated with psychiatric, neurological, medical and drug causes).
• Delirium and dementia (including frontotemporal dementia and Lewy body dementia).
• Neurological disease (epilepsy, encephalitis, stroke, tumour, head injury, Huntington disease, multiple sclerosis).
• Substance and drug related (intoxication, withdrawal, adverse effects).
• Metabolic, endocrine, infectious and autoimmune disorders.
• Neurodevelopmental disorders (intellectual disability, autism spectrum disorder) with distress or regression.
• Dissociative states, severe personality disorder and acute stress reactions.
• Self neglect syndromes (Diogenes syndrome, hoarding disorder).

Epidemiology. Disorganised symptoms occur in about 50% of people with schizophrenia at some stage. Catatonia occurs in about 10% of acute psychiatric inpatients and is often missed. Delirium affects 10 to 30% of acutely ill older medical patients. Frontotemporal dementia is a leading cause of dementia under age 65 years, with behavioural change preceding memory loss.

Mechanisms. Frontostriatal and temporal dysfunction in psychosis, dopamine and glutamate dysregulation, gamma aminobutyric acid deficit in catatonia, cholinergic deficiency in delirium and dementia, and structural or inflammatory damage to frontal, limbic and subcortical circuits.

Key distinctions.

• Acute onset with fluctuating attention and disorientation suggests delirium.
• Gradual onset in a young adult with hallucinations, delusions and flat affect suggests schizophrenia.
• Elevated mood, reduced sleep and pressured speech suggest mania.
• Immobility, mutism and posturing suggest catatonia.
• Insidious apathy, disinhibition, compulsive behaviour and loss of empathy in a patient aged 45 to 65 years suggest frontotemporal dementia.
• Rapid change with seizures, dyskinesias and autonomic instability in a young woman suggests anti-NMDA receptor encephalitis.

History (from the patient, family, police, ambulance and records)

• Onset (hours, days, weeks, months), course, tempo, and what changed from the person's baseline.
• Behaviours: wandering, hoarding, self neglect, undressing, inappropriate sexual behaviour, aggression, repetitive behaviour, mutism, stupor, excitement, and any danger to self or others.
• Speech: coherence, content, mutism, echolalia.
• Psychiatric symptoms: hallucinations, delusions, mood symptoms, mania, depression, anxiety, and suicidal thoughts.
• Cognitive symptoms: memory loss, disorientation, language problems, visual spatial difficulty, personality change, loss of empathy, and fluctuating alertness.
• Neurological symptoms: headache, seizure, fever, head injury, tremor, weakness, gait problems, incontinence, abnormal movements.
• Medical history: epilepsy, stroke, dementia, HIV, syphilis, diabetes, thyroid disease, kidney or liver disease, autoimmune disease, cancer, alcohol misuse, and recent infection or surgery.
• Substances: alcohol (including withdrawal), cannabis, stimulants, hallucinogens, ketamine, opioids, sedatives and new psychoactive substances.
• Drugs: antipsychotics (recent change, stopping, depot), corticosteroids, anticholinergics, dopamine agonists, antiepileptics, benzodiazepine withdrawal, baclofen withdrawal, lithium, and recent anaesthesia.
• Psychiatric and family history of psychosis, dementia, and epilepsy.
• Premorbid functioning, developmental history, learning disability, and autism.
• Social: living alone, isolation, exploitation, finances, medication management, safeguarding and risk to dependants.
• Capacity and legal status.

Observation and examination

• Level of consciousness and attention (4AT, months backwards), orientation, and fluctuation.
• Behaviour: posture, movement, stereotypies, grimacing, mutism, response to commands, eye contact, and signs of catatonia (Bush-Francis Catatonia Rating Scale: screening of the first 14 items, with 2 or more positive items suggesting catatonia; test for catalepsy, waxy flexibility, gegenhalten, mitgehen, grasp reflex, echophenomena, and ambitendency).
• Mental state: mood and affect, thought form (derailment, incoherence), thought content, perception, cognition (Montreal Cognitive Assessment), frontal tests (verbal fluency, Luria hand sequence, go-no-go), insight and risk.
• Vital signs: temperature (over 38 C suggests infection, neuroleptic malignant syndrome or malignant catatonia), pulse, blood pressure, respiratory rate, oxygen saturation, glucose, hydration, and weight.
• Neurological: cranial nerves, tone (lead pipe rigidity), tremor, reflexes, primitive reflexes, gait, focal signs, nystagmus, ataxia, and dyskinesias.
• General: signs of alcohol use, injection marks, malnutrition, pressure sores, signs of infection, thyroid, liver stigmata, skin rash, and injuries.
• Self care and environment: hygiene, clothing, home conditions, food, medicines and safety (home visit or collateral).

Red flags

• Fever, rigidity, autonomic instability, altered consciousness and raised creatine kinase (neuroleptic malignant syndrome or malignant catatonia).
• Acute confusion, fluctuating attention, or visual hallucinations (delirium).
• Stupor, mutism or refusal of food and fluids, with dehydration (catatonia).
• Head injury, seizure, headache, papilloedema, focal signs or neck stiffness.
• Wernicke encephalopathy features (confusion, ataxia, ophthalmoplegia) in a person with alcohol use or malnutrition.
• Alcohol or benzodiazepine withdrawal with tremor, sweating and hallucinations.
• First presentation after age 40 years, or marked personality change, disinhibition or apathy.
• Rapid onset psychosis with seizures, dyskinesias, autonomic instability, hypoventilation or catatonia (anti-NMDA receptor encephalitis).
• Immunosuppression, HIV, syphilis risk, or recent travel (CNS infection).
• Command hallucinations, suicidal or violent intent, or vulnerability to exploitation.
• Severe self neglect with malnutrition, infected wounds, unsafe housing, or inability to manage medicines.
• Postpartum onset with confusion or delusions.
• Lithium, antipsychotic or anticholinergic toxicity.
• Disorganised behaviour in a child with sudden regression, seizures or developmental loss.

Special groups

• Children and adolescents: disorganised behaviour may signal early psychosis, autism related regression, trauma, epilepsy, encephalitis (PANDAS or autoimmune), or substance use. Specialist assessment. Use age specific doses.
• Pregnancy and postpartum: postpartum psychosis, delirium, eclampsia and thyroid disease. Specialist care.
• Older adults: delirium, dementia, depression, polypharmacy, and late onset psychosis. Low doses of antipsychotics.
• People with intellectual disability or autism: behaviour change often signals pain, infection, constipation, seizures, or environmental change.
• Homeless and isolated people: self neglect, substance use and exploitation.
• Region specific: culturally normal behaviours in religious or spiritual practice, trauma in conflict, HIV, neurosyphilis, cerebral malaria, neurocysticercosis, trypanosomiasis, and khat.

Primary psychiatric

• Schizophrenia, schizophreniform disorder and schizoaffective disorder.
• Brief psychotic disorder.
• Bipolar disorder (mania, mixed episode, depressive stupor).
• Major depression with psychotic features or stupor.
• Catatonia associated with psychiatric disorders (mood, psychosis) or another medical condition.
• Delusional disorder with behavioural consequences.
• Autism spectrum disorder and intellectual disability with distress or regression.
• Dissociative disorders (dissociative stupor, fugue, trance).
• Acute stress reaction and posttraumatic stress disorder with dissociation.
• Personality disorders (schizotypal, borderline) in crisis.
• Obsessive compulsive disorder (severe) and hoarding disorder.
• Conversion disorder (functional neurological symptom disorder).
• Factitious disorder and malingering.

Delirium, dementia and neurological

• Delirium (hyperactive, hypoactive, mixed).
• Frontotemporal dementia (behavioural variant), Alzheimer disease, vascular dementia, Lewy body dementia.
• Huntington disease, Wilson disease, and neurodegenerative disorders.
• Epilepsy: temporal lobe automatisms, postictal states, nonconvulsive status epilepticus.
• Encephalitis (viral, autoimmune including anti-NMDA receptor), neurosyphilis, HIV encephalopathy and tuberculous meningitis.
• Stroke (frontal, thalamic, right hemisphere), brain tumour, subdural haematoma, hydrocephalus, and traumatic brain injury.
• Creutzfeldt-Jakob disease and progressive multifocal leukoencephalopathy.
• Multiple sclerosis and neuropsychiatric lupus.
• Narcolepsy and parasomnias with confusional arousals.
• Cerebral malaria and trypanosomiasis.

Metabolic, endocrine and systemic

• Hypoglycaemia, hyperglycaemic crisis, hyponatraemia, hypercalcaemia, uraemia and hypoxia.
• Hepatic encephalopathy and Wernicke-Korsakoff syndrome.
• Hyperthyroidism or thyroid storm, myxoedema, Cushing syndrome, Addison disease.
• Vitamin B12, thiamine and niacin deficiency.
• Acute intermittent porphyria.
• Sepsis, urinary and chest infection (older adults).
• Systemic lupus erythematosus, vasculitis, and paraneoplastic syndromes.
• Postoperative states and critical illness.

Substance and drug related

• Alcohol intoxication, withdrawal and delirium tremens.
• Stimulant, cannabis, synthetic cannabinoid, hallucinogen, ketamine and phencyclidine effects.
• Benzodiazepine, baclofen and barbiturate withdrawal.
• Anticholinergic, serotonergic, lithium and antipsychotic toxicity.
• Neuroleptic malignant syndrome and serotonin syndrome.
• Corticosteroids, dopamine agonists, levodopa, antiepileptics, isoniazid and fluoroquinolones.
• Carbon monoxide and other toxins.

Step 1. Safety and stabilisation. Assess risk, vital signs, level of consciousness and glucose. Treat dehydration, hypoxia and hypoglycaemia. Observe closely if risk is unclear.

Step 2. Screen for delirium and catatonia. Use the 4AT or Confusion Assessment Method in all patients with acute behavioural change. Screen for catatonia in anyone with stupor, mutism, agitation, posturing, negativism or unexplained immobility, using the Bush-Francis Catatonia Rating Scale (first 14 items, 2 or more positive) and a lorazepam challenge.

Step 3. First line tests

• Capillary glucose, oxygen saturation, temperature, 12 lead ECG.
• Full blood count, urea, creatinine, electrolytes (sodium), calcium, magnesium, phosphate, liver tests, CRP, creatine kinase, blood gas, lactate, and thyroid stimulating hormone.
• Vitamin B12, folate, HIV and syphilis serology, urinalysis and culture, blood cultures if febrile, chest radiograph.
• Urine and serum drug screen, blood alcohol, and lithium, valproate or other drug levels when relevant.
• Pregnancy test.
• Iron studies and serum iron (low in catatonia and neuroleptic malignant syndrome).

Step 4. Targeted tests

• CT head urgently for trauma, anticoagulation, focal signs or unclear cause, then MRI brain with contrast for frontotemporal dementia, encephalitis, tumour, demyelination and stroke.
• Electroencephalogram (diffuse slowing in delirium and catatonia from medical causes, epileptiform activity in seizures and extreme delta brush in anti-NMDA receptor encephalitis).
• Lumbar puncture with opening pressure, cells, protein, glucose, oligoclonal bands, herpes simplex virus PCR, cryptococcal antigen, syphilis serology and autoantibodies (NMDA receptor, LGI1, CASPR2), after imaging, with empirical aciclovir 10 mg/kg intravenously every 8 hours when encephalitis is possible.
• Serum autoantibodies (anti-nuclear antibody, anti-NMDA receptor), ammonia, porphyria screen, caeruloplasmin, cortisol, heavy metals, and paraneoplastic antibodies.
• Pelvic ultrasound or MRI for ovarian teratoma in suspected anti-NMDA receptor encephalitis, and tumour screening.
• Formal neuropsychological assessment and dementia work up (FDG PET or amyloid markers in specialist care) for suspected dementia.
• Occupational therapy assessment of daily living and home safety.

Step 5. Interpretation. A clear sensorium with typical positive and negative symptoms and a normal screen supports a primary psychotic disorder. A reversible cause should be sought even in known psychiatric patients, since diagnostic overshadowing is common. Response to a lorazepam challenge supports catatonia, and does not exclude an underlying organic cause.

Limits. Disorganisation is a nonspecific sign. Behaviour may be limited by lack of cooperation. Rating scales assist and do not diagnose. Low iron and raised creatine kinase are supportive but nonspecific.

Immediate

• Provide a safe, calm, low stimulation environment with consistent staff. Use simple language and avoid confrontation.
• Treat life threatening causes first: hypoglycaemia (glucose 20 g orally or 10% dextrose 150 to 200 mL intravenously), hypoxia, dehydration (isotonic crystalloid), sepsis, Wernicke encephalopathy (thiamine 200 to 500 mg intravenously three times daily), withdrawal and seizures.
• Agitation or danger: de-escalation, then lorazepam 1 to 2 mg orally or intramuscularly, or olanzapine 5 to 10 mg orally (do not combine intramuscular olanzapine with a parenteral benzodiazepine within 1 hour). Avoid antipsychotics until catatonia and neuroleptic malignant syndrome are excluded.
• Capacity and legal status: assess capacity for treatment decisions, and use mental health or mental capacity legislation when the patient cannot consent and treatment is necessary.
• Prevent complications of immobility and poor intake: fluids, nutrition, pressure area care, and thromboprophylaxis (enoxaparin 40 mg subcutaneously once daily, or 20 mg at creatinine clearance under 30 mL/min).

Catatonia

• Lorazepam challenge: 1 to 2 mg intravenously or intramuscularly, with reassessment of the Bush-Francis score after 5 to 10 minutes (oral or sublingual doses if parenteral access is unavailable, reassess after 30 to 60 minutes), repeating once if there is no response. A fall of 50% or more in the score supports the diagnosis.
• Treatment: lorazepam 1 to 2 mg three to four times daily, increased as tolerated to 6 to 8 mg daily (up to 16 to 24 mg daily in resistant cases under specialist monitoring), with monitoring of sedation, respiration and oxygen saturation. Continue for several weeks after resolution and taper slowly over 2 to 4 weeks or longer.
• Electroconvulsive therapy: first line for malignant catatonia, severe catatonia with food refusal, or lack of response to lorazepam within 3 to 5 days (response in 80 to 90%).
• Avoid antipsychotics during acute catatonia (risk of neuroleptic malignant syndrome). If psychosis requires treatment, use low dose aripiprazole or clozapine after catatonia has resolved, with close monitoring.
• Other options for resistant catatonia: zolpidem 10 mg challenge, amantadine 100 mg twice daily up to 200 mg twice daily, memantine 5 mg daily up to 10 mg twice daily, and treatment of the cause.
• Treat the underlying cause: mood disorder, psychosis, encephalitis (immunotherapy), medical illness.
• Malignant catatonia and neuroleptic malignant syndrome: intensive care, stop all antipsychotics, fluids, cooling, lorazepam, dantrolene 1 to 2.5 mg/kg intravenously every 6 hours (maximum 10 mg/kg daily), bromocriptine 2.5 mg three times daily orally, and electroconvulsive therapy.

Delirium

• Find and treat the cause (infection, drugs, metabolic disorder, retention, constipation, pain, hypoxia). Review drugs and stop deliriogenic agents (anticholinergics, benzodiazepines, opioids where possible).
• Nonpharmacological care: orientation, glasses and hearing aids, sleep protection, early mobilisation, hydration, family presence, and a quiet room.
• Drug treatment only for severe distress or danger, for the shortest time: haloperidol 0.5 to 1 mg orally or intramuscularly (repeat after 1 hour if needed, maximum 5 mg daily in older adults), or olanzapine 2.5 mg. Avoid in Parkinson disease and Lewy body disease (use quetiapine 12.5 to 25 mg). Alcohol withdrawal: chlordiazepoxide 20 to 30 mg orally every 6 hours reducing over 5 to 7 days, with thiamine.

Primary psychotic disorders

• Early referral to early intervention in psychosis services. Start low dose antipsychotic by shared decision: olanzapine 5 to 10 mg at night (maximum 20 mg), risperidone 1 to 2 mg daily (maximum 6 mg), aripiprazole 10 to 15 mg daily (maximum 30 mg), amisulpride 200 to 400 mg daily (maximum 1200 mg), or quetiapine 300 to 800 mg daily in divided doses. Review response at 2 to 4 weeks and switch after 4 to 6 weeks of inadequate response. Clozapine for treatment resistance (titrate 12.5 mg to 300 to 450 mg, maximum 900 mg, with blood monitoring).
• Long acting injectable preparations for poor adherence (paliperidone palmitate 150 mg on day 1 and 100 mg on day 8, then monthly 75 to 150 mg; aripiprazole 400 mg monthly; risperidone microspheres 25 to 50 mg every 2 weeks).
• Psychosocial interventions: cognitive behavioural therapy for psychosis, family intervention, cognitive remediation, supported employment and housing, and treatment of substance use.
• Mania with disorganisation: olanzapine 10 to 15 mg, risperidone 2 to 4 mg, quetiapine 400 to 800 mg, or lithium 400 mg at night titrated to 0.6 to 1.0 mmol/L, with valproate 20 to 30 mg/kg daily in men and in women who cannot become pregnant.
• Psychotic depression or stupor: antidepressant plus antipsychotic, or electroconvulsive therapy.

Dementia and neurological disease

• Frontotemporal dementia: structured routine, environmental safety, caregiver support, SSRIs (sertraline 50 to 150 mg daily, citalopram 20 mg daily) or trazodone 50 to 150 mg for disinhibition and compulsions, and avoid cholinesterase inhibitors and memantine, which may worsen behaviour. Low dose antipsychotics only for severe danger.
• Alzheimer and Lewy body dementia: cholinesterase inhibitors (rivastigmine 1.5 mg twice daily increased to 6 mg twice daily; donepezil 5 mg increased to 10 mg), nonpharmacological care, and rarely risperidone 0.25 mg twice daily (maximum 2 mg daily) for severe danger, and quetiapine in Lewy body disease.
• Epilepsy: antiepileptic treatment by seizure type; nonconvulsive status epilepticus requires lorazepam 4 mg intravenously then specialist antiepileptic loading.
• Autoimmune encephalitis: methylprednisolone 1 g intravenously daily for 3 to 5 days, immunoglobulin 0.4 g/kg daily for 5 days or plasma exchange, tumour removal, and second line rituximab 375 mg/m2 weekly for 4 weeks or cyclophosphamide, under specialist care.
• Herpes simplex encephalitis: aciclovir 10 mg/kg intravenously every 8 hours for 14 to 21 days (adjust for kidney function).
• Neurosyphilis: benzylpenicillin 18 to 24 million units daily intravenously for 10 to 14 days. HIV related disease: antiretroviral therapy. Cerebral malaria: artesunate 2.4 mg/kg intravenously at 0, 12 and 24 hours, then once daily.

Self neglect and safeguarding

• Assess capacity, risk to health and safety, and safeguarding concerns for the person and for dependants. Engage trusted contacts, social care and primary care, with a graded approach to cleaning, nutrition, finances and medicines.
• Occupational therapy assessment of function. Social work for housing, benefits and supported living. Use legal powers when capacity is lacking and risk is high, in the least restrictive way.

Special populations

• Pregnancy and breastfeeding: specialist care. Postpartum psychosis is an emergency requiring admission, ideally to a mother and baby unit. Use olanzapine, quetiapine or haloperidol where possible, and lorazepam for catatonia.
• Children and adolescents: specialist assessment and treatment, with metabolic monitoring if antipsychotics are needed.
• Older adults: low doses, review of drugs and falls, avoid long term sedatives.
• Kidney and liver impairment: reduce lorazepam, olanzapine, risperidone and amisulpride doses (amisulpride halved at creatinine clearance 30 to 60 mL/min).
• Intellectual disability and autism: treat pain, infection and constipation, adapt the environment, and involve carers.

Monitoring. Level of consciousness, vital signs, hydration, food and fluid intake, Bush-Francis score in catatonia, delirium scores daily, behaviour charts, weight, creatine kinase and renal function in catatonia, metabolic indices on antipsychotics, ECG, adherence, and risk review.

Referral and escalation. Psychiatry the same day for primary psychosis, mania, catatonia and risk.

Neurology for encephalitis, epilepsy, dementia and movement disorders. Medicine or geriatric medicine for delirium. Intensive care for malignant catatonia, neuroleptic malignant syndrome and Wernicke encephalopathy with instability. Old age psychiatry, early intervention in psychosis, addiction, social work, occupational therapy and safeguarding services.

Admission criteria. Delirium, catatonia, inability to eat or drink, severe self neglect, risk to self or others, vulnerability to exploitation, severe agitation, unclear organic cause with abnormal vital signs, suspected encephalitis, and failure of community care.

Discharge and follow up. Written crisis plan, medication and carer education, early review in 1 to 2 weeks, community mental health follow up, and social support package. Safety net advice: return for fever, stiffness, mutism, refusal of food or drink, new confusion, seizures, hallucinations with commands, thoughts of harm, falls, or stopping of medicines.