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Psychosis Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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% Copyright © The REACH Institute. All rights reserved. Medical Causes of Psychosis • • • • • CNS infections Delirium Neoplasms Endocrine disorders Genetic syndromes – (e.g., velocardiofacial [22q11] syndrome) • Autoimmune disorders • Toxins Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved. Evaluation of Psychosis • • • • • Core Symptoms Impairment and Function Drug Toxicology Screen R/O CNS Lesion (MRI) R/O Other Medical Conditions Copyright © The REACH Institute. All rights reserved. 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) Copyright © The REACH Institute. All rights reserved. Psychosis Treatment: Chronic • Patients in your practice – Schizophrenia – Other disorders with psychotic symptoms • Identification and management of adverse effects – Coming up next! Copyright © The REACH Institute. All rights reserved. Q&A Ask The Experts Copyright © The REACH Institute. All rights reserved. REMINDER: Please fill out Unit M evaluation Copyright © The REACH Institute. All rights reserved. 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. Copyright © The REACH Institute. All rights reserved. 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 Copyright © The REACH Institute. All rights reserved.