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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
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Epidemiology of Psychosis in Children and Adolescents
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 PsychosisMedical Causes of Psychosis
• 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
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
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 & YouthCore Cognitive Symptoms of
Psychosis in Children & YouthDelusions
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
• 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 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 13-17
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
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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