Transcript Psychosis - The REACH Institute

Psychosis
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Learning Objectives
• Differentiate among psychosis and other
pediatric behavioral health problems with
psychotic features
• List cognitive symptoms of psychosis
• Describe treatment options and clinical
recommendations when selecting and using
medications for psychosis
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What is Psychosis?
• Severely disrupted thought & behavior resulting in
loss of developmentally appropriate reality testing
• Overt changes in function, w/evidence of disrupted
thinking on mental status exam
• Psychotic symptoms - characteristic of
schizophrenia, but do occur in other illnesses, e.g.:
– mood disorders
– neurologic conditions
– acute intoxication
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Epidemiology of Psychosis in
Children and Adolescents
• Children < 12 years old
– Schizophrenia is very, very rare
– Consider non psychiatric causes, MDD with
psychotic features, bipolar disorder, severe PTSD,
or other potential ideologies
• Adolescents 13-17 years old
– Schizophrenia = 0.3-0.5 percent
– Same considerations as above
• Adults > 18 years old
– Schizophrenia = about 1%
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Medical Causes of Psychosis
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CNS infections
Delirium
Neoplasms
Endocrine disorders
Genetic syndromes
– (e.g., velocardiofacial [22q11] syndrome)
• Autoimmune disorders
• Toxins
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Substances That May Cause
Psychosis
• Dextromethorphan, LSD, hallucinogenic
mushrooms (e.g., psilocybin, peyote), MJ,
stimulants, inhalants
• Steroids, anesthetics, anticholinergics,
antihistamines, amphetamines
• Acute psychosis due to intoxication usually remits
within days to weeks after substance is D/C’ed
• Sometimes schizophrenia (and/or unresolved
psychosis) first presents after substance ingestion
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Symptoms That May Seem
Psychotic in Children
• Illusions: Sounds and visualizations at
night often associated with anxiety
• “Voices”: Often a single voice telling the
child to do something “bad”
• Imaginary Friends
• Fantasy: In young, cognitively-delayed
or language-delayed child
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Core Cognitive Symptoms of
Psychosis in Children & Youth
Delusions
 Ideas of reference
 Belief of be persecuted or controlled
Hallucinations
 Usually auditory, threatening voices giving
comments, laughing , humming
 Visual hallucinations appear more common in
children under age 13
Thought Distortions
 Breaks in the train of thought – so-called
“private logic”
 Incoherent vague thoughts
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Asking kids about psychosis
• Things to say & ask: “Lots of times kids hear or see
weird, funny, or even scary things they aren’t sure are
real…”
– “Does your mind ever play tricks like that on you?”
– “Do you hear voices talking to you when no one is there?”
– “Does your mind ever feel confused”
• Youth can often describe relevant aspects of their
psychotic symptoms, but some are too disorganized,
confused, and/or paranoid to give accurate details or
hx
• Parents, family members, teachers, and treatment
providers are important sources of information for
identifying changes in behavior, thinking, or function
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Evaluation of Psychosis
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Core Symptoms
Impairment and Function
Drug Toxicology Screen
R/O CNS Lesion (MRI)
R/O Other Medical Conditions
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Psychosis Treatment: Acute
• Referral for emergency/crisis care, if needed
• Referral for psychiatric consultation, if
possible
• Use of antipsychotic medication, as needed
• FDA approved for schizophrenia (ages 1317 y.o.)
– Aripiprazole (Abilify)
– Risperidone (Risperdal)
– Olanzapine (Zyprexa)
– Quetiapine (Seroquel)
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Psychosis Treatment: Chronic
• Patients in your practice
– Schizophrenia
– Other disorders with psychotic symptoms
• Identification and management of adverse
effects
– Coming up next!
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Q&A
Ask The Experts
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REMINDER:
Please fill out Unit M
evaluation
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RESOURCE SLIDE:
Psychiatric Disorders other than Schizophrenia
that may present with psychotic symptoms
• Schizoaffective disorder
– psychotic symptoms plus prominent mood episodes (meeting full
criteria for mania or depression) that are present for a substantial
duration of the illness
• Psychotic mood disorders (especially bipolar disorder)
– Full-blown mania in teenagers often presents with florid psychosis,
including hallucinations, delusions, and thought disorder
– Psychotic depression may present with hallucinations or delusions
• PTSD and or abused youth are esp. vulnerable to report
psychotic-like symptoms - dissociation and/or anxiety,
intrusive thoughts/worries, derealization, depersonalization,
etc.
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RESOURCE SLIDE:
Emergency Medication for
Psychosis
• Olanzapine orally disintegrating
Tabs (Zydis)
– 5-10 mg PO once prn
• Risperdal M-Tabs
– 1-2 mg PO once pm
• Ziprasidone IM
– 10-20 mg IM once prn
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